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\ 



THE 

Neurological Practice of Medicine; 



A Cursory Course of Selected Lectures 



IN 



Neurology, Neuriatry, Psychology and Psychiatry; 
Applicable to General and Special Practice. 

WITH 177 ILLUSTRATIONS. 



AFTER THE AUTHOR'S CLASS-ROOM METHODS AS A 
TEACHER OF STUDENTS. 



DESIGNED FOR STUDENTS AND GENERAL PRACTITIONERS OF MEDICINE 

AND SURGERY. 



By CHARLES II. HUGHES. M. D.. 

President of the Faculty and Proiessor of Neurology, Psychiatry and Elec- 
trotherapy, Barnes Medical College. Former Major and Surgeon-in- 
Chief of Schofield, 'Winter, Hickory Street, and McDowell's 
College Military Hospitals. Superintendent Missouri State 
Insane Hospital. Acting and Honorary Member 
of Many Home and Foreign Medical and 
Scientific Societies, Fic. f Klc. 

Member Governing Hoard of Centenary Hospital. Kx-Member Hoard of 
Health and Consultant of City Hospital. Insane Hospital, Ktc. 

IOC) 3 . 



'/jtss ' 



• * * * •• • • 



PART I. 






TABLE OK CONTENTS. 



Page 
TITLE PAGE ------- 1 

COPYRIGHT ------- 2 

DEDICATION ------- 3 

INTRODUCTORY ------ 4-9 

EDITOR'S PREFACE ------ 10-11 

CHAPTER I - 12-22 

Preliminary Essential Definitions, Etc. Neuroanatomy, Neu- 
rology. Neuriatry, Psychology, Psychiatry, Neurophysiology, 
Neuropathology, Neurotherapy, Psychotherapy, Psychopath- 
ology, Alienist, Psychiater, Neuriater, the Neurone, Nerve 
Center, Etc., Etc. 

CHAPTER |i------- 23-35 

The Neurone and the Nerve Cells; Their Composition and 
Characteristics. 

CHAPTER III ------ 36-42 

The Neurone and the Nerve Centers, Continued; the Neu- 
rone Conception or Theory, Association Neurones, Projection 
Fibers, Etc. 

CHAPTER IV------- 43-47 

The Neurone Continued; Its Efferent Prolongation or Prolifera- 
tion. The Axone, Neuraxone, Neurite or Axis Cylinder Pro- 
cess; the Nerve Cell and Its Belongings. Histological Compo- 
sition of Nerve Centers. The Neurone and Its Dendrites or 
Afferent Cell Processes. The Neuroglia. 

CHAPTER V------- 48-56 

Outline Forms and Functions of Neurones. Polar and Apolar, 

[i] 



BipoUr and Haiopour Neurones. Neurone and Nerve Ceil: 
Synonymous :s a Broad Sense. Disease Changes :n the 
Neuroses. 

CHAPTER VI ------ - 57-69 

The Neurones Grouped into Layers or Strata of the Brain Cor- 
tex; Farther Consideration of the Neurones and or the Asso- 
ciated Fiber System of the Brain ar.i or the Pro;ecr.:n System 
of the Brain and Spinal Cori. Functions o: Neuroglia and 
Mesogiia. 

CHAPTER VII ------- 70-52 

Head Heat in Brain Disease. Cerebral Thermometry, and Ceph- 
alic Galvanization. Their Value in Diagnisis and Practice. 

CHAPTER VIII - - - - - - - S3-S9 

The Temperature Sense, Etc. . and Its Alterations in Diagnosis. 

CHAPTER IX ------ 9O-10O 

Extra-Neural or Adneural Nervous Disease. Systematic States 
Leading to. Proceeding from and Blending with Nervous Dis- 
ease; Malaria. Erythrocytes. Thermasia. Thermesthesia; 
Their Effects on the Neurones. Etc. 

CHAPTER X ------ 101-116 

Extra- Neural or Adneural Nervous Disease. Chromatic and 
Achromatic Neurones. Chromitoiysis. Thermal Changes in 
the Neurones. Brain Neurones as Hea: Centers. Adneural 
Heat Changes of Neurones. Mamescos and Lugaro's 
Law of Morbid Neurone Change. Rertex Phenomena and the 
Neurones. 

CHAPTER XI - - ----- - 117-136 

Instruments and Procedures of Precision in D.agnosis and 
Practice. 

CHAPTER XII ------ - 13S-147 

Instruments of Precision (Continued;. 

CHAPTER XIII - 14S-15o 

Instruments of Precision 'Concluded). The Sphygmograph. 
the Percuteur and Polygraph in Practice. 

CHAPTER XIV 157- 1^ 

Ascending and Descending Degeneration. Peact'on of Degen- 
eration; Waller's Law: Its Diagnostic Si^mricance. 



lit 

Page 

CHAPTER XV 164-170 

The Reaction of Degeneration and Its Use in Diagnosis. How 
to Discover It. Applicable Cases. 

CHAPTER XVI 171-177 

How the Reaction of Degeneration is Diagnosticated. 

CHAPTER XVII ------ 178-182 

Another View of the Reaction of Degeneration. 

CHAPTER XVII I 183-195 

The Evolution of the Neuraxis. Nature's Building of the Brain 
and Spinal Cord. 

CHAPTER XIX ------ 196-210 

The Evolution of the Brain and Spinal Cord or Neuraxis (Con- 
tinued). 

CHAPTER XX 211-225 

History of the Evolution of the Brain. Some Further Facts 
Concerning the Brain. 

CHAPTER XXI - - - - - - - 226-241 

The Brain's Blood Supply. The Intercranial Circulation in 
Its Relation to Brain Disease. 

CHAPTER XXII ------ 243-251 

Electricity and Electrical Appliances. 

CHAPTER XXIII ------ 252-265 

The Dura; Its Sinuses and Diseases: A Cursory Anatomical 
Demonstration. 

CHAPTER XXIV ------ 266-282 

Cerebral Embolism, Thrombosis and Hemorrhage, and Some of 
Their Sequent Brain Diseases Cursorily Considered. 

CHAPTER XXV 283-300 

The Anatomy of the Spinal Cord, With Brief Reference to Its 
Morbid States. 

CHAPTER XXVI ------ 301-307 

Nerve Centers (Continued). Psycho-Motor Centers — Visual 
Apparatus Centers — Other Motor Reflex Centers. 

CHAPTER XXVII ------ 308-327 

The Sensori-Motor System in Diagnosis. The Reflexes. 



iv 

Paee 

CHAPTER XXVIII 328-344 

The Cerebrospinal Axis or Neuraxis and Its Nerve Centers. 
Ganglia. Plexuses, Neurones and Nerve Centers, Importance 
of the Pupil and other Nerve Centers in Diagnosis. The Basal 
and Other Ganglia. The Neuraxis and the Neurone. 

CHAPTER XXIX 345-351 

The Neuraxis Again. Diagnostically Viewed. A Cursory Dem- 
onstration of Cranial Nerves. The Oluans of the Spinal 
Cord and the Nerves that go to and from It. The Cord Seg- 
ments of Impression and Influence. Outline of the Cerebral 
and Spinal Nerves and Nerve Centers and Their Relation to 
Nervous Disease. 

CHAPTER XXX 352-369 

Outline of the Cerebral and Spinal Nerves and Nerve Centers 
and Their Relation to Nervous Disease. Etc.. (Continued). 

CHAPTER XXXI 370-378 

The Virile or Genesiac Reflex and Its Symptomatic Value in 
Practice. 

CHAPTER XXXII ------ 379-391 

Aphasia Defined and Located. Aphasia Physically and Psy- 
chically Considered. Some of Its Most Essential Phases Dis- 
cussed. 

CHAPTER XXXIII ------ 392-399 

The MeJico-Legal Aspects of Aphasia. The Case of Wm. T. 
Bevin . 

CHAPTER XXXIV ...... 400-406 

Psychological Analysis of the Bevin Case Concluded. 

CHAPTER XXXV .--... 407-413 

The Neural and Psycho- Neural Aspects of Surgical Practice. 
Lumbar Puncture as an Anaesthetic. Turner's Lumbar Puncture 
in Surgical Diagnosis and Prognosis. Lumbar Puncture and 
Neuro- or Cyto- Diagnosis. Idutrophic Affinities and Reac- 
tions of Neurones. 

CHAPTER XXXVI ..._.. 414-417 

The Nutrition and Conservation of the Neurones, or Neuro- 
and Psychotherapy in Surgery. The Psychiatric Factor in 
Surgery'- Psychical Depression and Neuropathic Diathesis. 
Post -Operative Insanity. 



LECTURES ON NEUROLOGY AND NEU- 

RIATRY, PSYCHOLOGY AND 

PSYCHIATRY. 



AFTER THE METHODS OF THE CLASS-ROOM, TO THE AUTHOR'S 
STUDENTS, AND DESIGNED ALSO FOR GENERAL PRAC- 
TITIONERS OF MEDICINE AND SURGERY. 



By C. H. HUGHES, M. D„ 

Member American Medico- Psychological Association, Honorary Member of 
New York Medico- Legal Society, British Medico- Psychological Associa- 
tion, Foreign Member of Russian Society of Neurology and Psychiatry, 
Honorary Fellow of Chicago Academy of Medicine, Ex-Member 
of Judicial Council and of the Executive Board A. M. A., 
Ex-Supt. and Physiclan-in-Chief Mo. State Hospital 
for the Insane, Ex-Pres. Miss. Val. Med. Ass'n, 
American Med. Editors' Ass'n, and Ex-Pres. 
of Section on Neurology American Med. Ass'n 
and Pan-American Med. (Congress, Ex- 
vice- Pres. Sections Physiology and 
Psychiatry, Med. Congress, 1876, 
Pres. of Faculty and Prof, of 
Neurology, Psychiatry and 
Electro - Therapy Barnes 
Medical College, etc., 
etc., St. Louis. 



EDITED BY PROF. MARC RAY HUGHES, M. D., 
BARNES MEDICAL COLLEGE, 
ST. LOUIS. 



Press of HUGHES & CO.. 418 N. Third Street, St. Louis. 



DEDICATION. 

TO MY PAST AND PRESENT STUDENTS NOW LIVING 
IN THE SEVERAL STATES OF THIS AMERICAN UNION 
AND IN COUNTRIES ABROAD who havk stood about 
me at the anatomical table or sat around or before me in 
the amphitheater of the three colleges in which 1 have 
lectured, the Barnes, the Marion-Sims and the St. Louis, 
now the Medical Department of Washington University, 
this book, containing the substance of a selected part of my 
lectures on the great themes of neurology and neuriatry, 
is fraternally and cordially dedicated. 

Like the diploma with which you went out from 
college or hope to take out as your shield in the battle of 
your professional life, these lectures represent the com- 
mencement of your medical career, in its neurological aspects 
and the neuriatric search light, your friend and servitor 
has endeavored to throw on your pathway. 

If by this light your way has been made easier to walk 

or shall be further illumined, the pleasure of knowing that 

your welfare will have been thus promoted, will prove ample 

reward for the author's pains in preparing these lectures in 

book form, in the midst of a busy professional life. 

"If he hath lent strength to the weak" 

***** 
"Or let in a ray of sunshine" 

that has made any dark and crooked path in neurology or neu- 
riatry bright and straight to you, his labor has not been in 

vain. 

THE AUTHOR. 

[3] 



INTRODUCTORY. 

This book aims to lift students along their arduous way, 
over the neurological obstacles in their path, especially those 
who have been under the author's instruction. 

It does not aim to go all the way or point out all 
the paths, but some of the best neurological roads for the 
general practitioner to follow. 

It is hoped, that of the many who have heard the 
author's lectures, the most of them will look over these pages 
with pleasure and profitable retrospective memory, as the 
author does, while others yet to hear or read his teachings, 
will find them instructive and labor-saving. 

Among master minds in medicine, neurology and the 
neurological aspects of disease, and neuriatry and psychia- 
try, and the management of the nervous system and mind 
in the conduct and cure of disease in general, are justly 
claiming more attention than in the past. 

Through anatomical, physiological, chemical, bacteriolog- 
ical, cytological and haematological discovery, the views of 
Cullen and his contemporaries are receiving, of late, more 
neuro- physiological amplification and illumination than in 
the days of the great nosologist and clinician of the closing 
eighteenth and beginning nineteenth centuries. 

We are approaching and standing upon surer and 

sounder clinical ground and, as we see with more scientific 

precision, we begin to discover, notwithstanding the great 

value of other departments of medico-scientific research, 

[4] 



the supreme importance of a knowledge of the nervous sys- 
tem in the practice of medicine. 

As I have before predicted,* Neurology is yet destined 
to reign paramount in clinical medical thought, notwith- 
standing the conceded just importance of every depart- 
ment of practical medicine. 

The successful treatment of disease consists in the 
proper management of the entire man. With certain local 
exceptions the problem is a neurohaemic questiont and the 
tone and quality and conditions of the nervous system are 
evermore uppermost in the study and treatment of disease, 
whether we aspire to be an especially qualified neurologist 
or a practitioner over other areas of the human anatomy, 
but with an adequate knowledge of its important neural rela- 
tions. 

Those who have heard the author in his lectures touch 
on neurology in general, know that he believes that the 
field of neurology must widen in practice till it ceases to 
be a special department of medicine, save in its essential 
manipulations, as many other fields of medical work now 
regarded as specialties must eventually become. 

The practitioner of medicine will become the clinical 
neurologist in ordinary practice, while extremely expert 
neurologists will become consulting neurologists and neu- 
riatrists to the profession, advisers and coadjutors in the 
neural aspects of ordinary disease and masters in applied 
neurotherapy in such cases as the general practitioner can 
not have the instruments or manual dexterity or the time or 
the clinical experience to properly treat. 

The practice of medicine has become so great a field of 
human endeavor that it is impossible for any one man to 



♦Dedication of Alienist and Neurologist. 1880. 
Mddrtss In Medicine Amer. Med. Ass'n. San Francisco. 1887. 



operate over its entire area. He may think it over, but to 
work all over it, is now impossible to human capability. 
We have reached the epoch of division and exchange of work. 
Whether or not you who read may coincide with me, 
this fact you, I believe, will always find to be a truth in 
practice; the nervous system understood up to date in its 
structure, functions and management, will prove a constant 
source of intellectual pleasure and profit in the understand- 
ing and treatment of all disease. To be a good neurologist, 
to express it in phrase Chesterfieldian, is to be the "high- 
est style" of physician. 

These chapters, as you who have heard my lectures 
will discern, are not complete, even as they were delivered. 
They omit some and include other matters touched upon in the 
amphitheater and embrace also some subjects more elaborately 
referred to in the class-room and clinic and some matters less 
extensively mentioned, as in the cerebro- neural demonstra 
tions. It is only as milepost helps and signboard guides to 
your neurological journey, that this matter is put in book 
form. You have become accustomed to my ways of pre- 
senting matters of moment to you in neurology. It will help 
you some, like the repetitions of phonography, to have this 
book with you when you wish to review your studies and 
refresh your minds now jaded with the multifarious demands 
of college work, after more leisure shall have come to you 
in the vacation interim of the college curriculum or while 
in practice. Besides this, the book, 1 hope, will keep 
us closer together in that cordial, friendly relationship which 
is now and has ever been so pleasant to us as teacher 
and learner. And 1 have myself been a learner, for he who 
constantly teaches an intelligent body of young gentlemen, 
continually learns more and more as he teaches. There is 
an inspiration to further study and research in an earnest 



knowledge seeking audience of young industrious students 
energetically determined, as you are or have been, to 
acquire the highest of all knowledge, neurology, embrac- 
ing as it does, psychology and psychiatry, in the study and 
understanding of man. 

Knowing that you are to benefit or harm the world 
by what you acquire or fail to acquire from my teaching, 1 
have felt the grave responsibility. Many a time after a lecture 
or demonstration, realizing that I did not come up to my ideal 
of how the knowledge you needed and how much of it should 
have been imparted, I have gone to the fountain sources in 
the late hours of midnight or early hours of morning for more 
light, in order that you might not be deprived of the neces- 
sities of your future professional success, in ministering to 
the welfare of those who are to trust you with their 
health and their lives. 

So, though you may not have thought it at the time, 
you have spurred me on. I have studied with you. We 
have together, though separated, burnt the midnight oil or 
early morning lamp, seeking for more light, as Ajax prayed, 
to win the conquest of Neurological Truth in which you and 
1 alike have been interested for the good of our fellow man. 

I have delved in higher ledges of the mine of neurologic 
truth than you, but my chief inspiration has been to cast the 
product of my delving into your level in good "pay dirt" 
from which you might "pan out" the precious metal of 
neurological fact to be worked by you into instrumentalities 
of neuriatric relief for man and woman in your respective 
spheres of influence in the world. 

I have reached up to the ledges where Obersteiner, 
Obermier, Wundt, Fritz, Hitzig, Heubner, Hugenin, 
Oppenheim and his master Carl Westphal, Edinger, 
Hirst, Nothnagel, Mendel, Mickel, Meynert, Morison, Ross, 



8 

Fournier, Bastian, Ireland, Drummond, Clouston, that English 
Coryphaeus Gowers, the brilliant Charcot, Fere, and others 
of his pupils, and the talented Vangehuchten, have worked 
and I have handed samples of their work down to you. 
I have done the same with the researches of our own 
geniuses in Neurology, Spitzka, Hamilton, Webber, Shat- 
tuck, Church, Chaddock, Pearce, Petersen, Putnam, Dana, 
Fisher, Kiernan, Mills, Sachs, Moyer, Wier Mitchell, Cle- 
venger, Dercum, Knapp, Lloyd, Mann, Starr, Shaw, Wood, 
the plates and sections of Fuller, Flower, and the indispensable 
Quain's Anatomy, Jacobs' beautiful pictures of anatomical 
art and the contributions of the lamented Seguin, Amidon, 
Gray and Hammond and the promising but prematurely cut off 
Shaw, Mink and Hazard of St. Louis. 1 have sometimes found 
a jewel in the work of Trouseau and of Watson, those medical 
Adisonian thought painters, who wrought medical observation 
into captivating and true speech center work, before ever I 
was brought forth or dreamed of instructing a class of hungry 
ante partem Doctors in the entrancing mysteries of neurol- 
ogy. 1 have traveled far and long into the fields of our 
science and picked a jewel here and there, burnished, or in 
the rough, and some of them, by no means all, 1 have given 
to you as generously as they have been freely given to me, 
hopeful of their helping you as they have aided me. 

These lectures aim to be up to date so far as they go. 

In some respects they are a little advanced, especially 
as regards the reflexes, over current text- books. 

They make no pretensions to completeness. 

Their aim is clearer elucidation of already traveled 
roads in practical neurology. 

No single volume could compass the entire field of 
neurology, even exclusive of neuriatry and psychiatry. 

No author should attempt it or could compass the whole 



field for the general practitioner or even for college students, 
in one volume. 

There are no entirely original lectures in any depart- 
ment of medicine in these days of community of interest 
and free research in our noble profession, and it is 
noble because it is a fraternity of mutual endeavorers for 
the welfare of the world. Each takes what his fellow 
produces and adds what he can in turn to the common 
store for the next one to use for further discovery and 
more extended utility. Methods of presentation must 
therefore naturally be more original than the materials 
of any modern book on Neurology, not excepting the one 
I now offer you. 

I give thanks to my worthy sons, Doctor Mark Ray 
Hughes, now adjunct to my chair, and to Hejiry L. Hughes, 
for valuable aid in editing and in revising proofs, etc. 

C. H. HUGHES. 
3860 West Pine Boulevard, 
St. Louis. 



EDITOR'S PREFACE. 

This book, as the advanced reader will see, is intended 
to cover some ground not quite so minutely covered in my 
father's, Professor Charles H. Hughes' regular lectures, and 
other ground more briefly than when delivered before the class. 

The aim has been, as I have it from the author, to be 
helpful, suggestive, plain, clear, practicable, retrospective 
and not too technically scientific for the undergraduate nor 
yet uninteresting for the post-graduate. The author's de- 
sign has been to present a familiar series of talks like a 
book that has once been gone over and thumbed and 
marked by his classes, making things already known to 
them a little better known and more clearly recalling matters 
perhaps but partly remembered in the course. 

Where repetitions occur, they have not been entirely 
unintentional, but have been permitted to remain in order 
that the impression of the facts may be fixed in the minds 
of the students. Hence the familiar style of the lecture 
room appears in the chapters and some sentences perhaps 
not severely appropriate to an exclusively scientific book. 

The author pleads consideration of his busy professional 
life in extenuation of the many faults of this hastily pre- 
pared volume, especially of facts of omission and undue 
prolixity of diction, as dictated to the editor. 

He also hopes his good purpose of serving the needs 
of the medical student in neurology will contribute to secure 
generously charitable judgment on the book's defects. 

The editor's part of this work has consisted mainly in 

[10] 



11 

shaping it for publication. All of the chapters have been 
transcribed essentially as dictated except the chapter on the 
Psychological Consideration of the Penitentes, of which the 
editor is the sole author. For this he invokes the generous 
indulgence of the critical reader. 

MARC RAY HUGHES, M. D., 
Adjunct Professor of Neurology, Psychiatry and 
Electro- Therapy, Barnes Medical College. 
3857 Olive Street, 

St. Louis. 



CHAPTER I. 

PRELIMINARY ESSENTIAL DEFINITIONS, ETC. NEUROANATOMY, NEUROL- 
OGY, NEURIATRY, PSYCHOLOGY, PSYCHIATRY, NEUROPHYSIOLOGY, 
NEUROPATHOLOGY, NEUROTHERAPY, PSYCHOTHERAPY, 
PSYCHOPATHOLOGY, ALIENIST, PSYCHIATER, 
NEURIATER, THE NEURONE, NERVE 
CENTER, ETC., ETC. 



You cannot advance satisfactorily in the study of 
neurology, which comprehensively embraces neuroanatomy, 
neurophysiology, neuropathology, neurochemistry, neuro - 
diagnosis, psychology, psychiatry, etc., without clearly 
comprehending at least the terms named in this chapter 
which we will define before proceeding further. Neuro- 
anatomy is nerve anatomy, as its derivation implies, 
vtvpov t a nerve and tc^vciv, to cut. avaro/ty, dissection, 
ava-Tefivttv, of or pertaining to the dissection of the nerve 
tissue. For example, v€vpov 9 nerve and iraOos, disease, 
suffering, neuropathology, the pathology of the nerves, 
relating to nervous system or nerve centers, etc. Neurop- 
athy, disease of the whole or any part of the nervous 
centers; a condition of general or local nervous disease. 
A good example of a general nervous disease or disease 
of the general nervous system is, neurasthenia, a 
condition of general nervous debility dependent on general 
functional neuratrophia or deficient nerve center nutri- 
tion, with often an inherent constitutional predisposition 
to become nervously weak, and with, consequently, functional 

[12] 



13 

weakness and instability or unsteadiness of the nervous 
system; a general functional disease of the nervous 
system. (vefyw, a nerve, «, privative or minus — and 
Ocvos, strength.) Another general nervous functional 
disease is hysteria, which is a very nervous condition, 
formerly attributed to the influence of the womb, though 
men may have it. The influence of the womb's dis- 
eases, the weakening effects of its functions when acting 
morbidly and of exhausting nursing, woman's indoor rou- 
tine, sedentary and monotonous life, etc., the recurring 
catamenia and its stoppage at the change of life, or climac- 
teric as it is called, though the life is not changed except 
to go on to another stage in its evolution till the decadence 
of age appears, contribute to bring about states of nerve 
strain and exhaustion which give the preponderance of 
hysteria, neurasthenia and climacteric nervous states to the 
female sex in mankind. Great brain and nerve-strain at 
the climacteric and senile epochs and from brain overwork 
or worry tend to cause nervous break -down and grave 
nervous diseases. 

Consult the derivations in your medical and unabridged 
general dictionaries and familiarize yourselves with the deriv- 
ative terms wherever you can find them, since one term well 
understood in its derivation or derivations will often give 
you signal aid in the understanding of many other medical 
definitions, especially compound words, and thus lighten the 
labor of study and give a philological zest to it. Thus you 
have already discovered that the radical word neuron, per- 
tains to nerve, nerve cell or center, and it is embraced in 
nearly all the words we have thus far mentioned, and plays 
a great part in medical nomenclature. 

Other specially important derivations with which you 
should become familiar are pathos (wu0os) f disease, thenos 



14 

(&w), strength, and aesthesias, (aurfopK) sensibility, and 
itis, Latin for inflammation, wherever you may find it in your 
studies. You will encounter the words neuropathy, nerve 
disease, and psychopathy, mental disease, neuritis, nerve in- 
flammation, phrenitis or cerebri tis, delirious brain or cerebral 
disease, neurasthenia or nervous debility, hyperesthesia 
or increased general sensibility, anaesthesia or absence of 
sensibility, hypoaesthesia, lessened general sensibility, ther- 
moaesthesia or sensibility to heat, hypo and hyper aesthe- 
sia meaning minus or plus heat sensitiveness, hypoalgesia 
and hyperalgesia signifying minus or plus sensibility to 
pain below or above the normal and so on. 

Look up these terms and their derivations often in your 
dictionaries (I speak to the juniors especially now), and we 
shall get along swimmingly for awhile. Do not be offended 
at my assuming that some of you may not know all these 
derivations and definitions. No harm will be done if I tell 
you something that you already know, but great harm to your 
progress may be done if I omit making your pathway as 
plain and easy to travel by these timely suggestions, as I 
can. It is my duty to clear the way for you as much as 
possible. I would make it plainer and easier if I could, but 
1 do not "know it all" myself — not so much as some of 
the seniors, perhaps, for seniors know very much; they have 
caught on ahead of you, you know. But since our time 
of study together is so brief, if I am as explicit as I can be 
I may be able to impart to you most of what I know before 
the time shall arrive for your final examination. I will do it 
if 1 can and if you will give me your attention. You will 
not be examined beyond what you may hear or see in these 
lectures and demonstrations. 

There is another and more special meaning of the term 
neuron, which some neurologists, especially that American 



15 

neuroanatomical investigator, Lewellys F. Barker,* As- 
sociate Professor of Anatomy and Resident Pathologist of 
the Johns Hopkins University and Hospital, now calls neurone 
to distinguish it from the general term expressed in the 
original Greek root, and which, as 1 have said, signifies nerve 
or nervous. The term neurone or neuron has come into use 
since Golgi,of Pavia, the great Italian cerebro-anatomist, gave 
to the scientific world about two decades ago, his remark- 
able studies of the fine anatomy of the brain, which you 
may find, after you get further advanced in the study of the 
nervous system and acquire that insatiable thirst for deeper 
knowledge which invariably comes to the enthusiastic 
student of neurology, in back numbers of the Alienist 
and Neurologist (1883) which was the first and only 
English or American journal of that day to place before 
the English- speaking neurological reader the advanced work 
of this distinguished savant in the field of cerebral discovery. 

Golgi's lucid findings in the minute anatomy of the brain 
led to another remarkable epoch-making discovery in neuro- 
anatomy, the naming, finding and defining of the neurone 
and its processes by those eminent micro-neuroanatomists and 
neurophysiologists, Ramon y Cajal, His and Schafer. They, 
with Nissl, Vangehuchten, Waldeyer, Harris, Held, Forel, 
our distinguished Barker, Hoch, and many others (more 
than I can mention) have added so much new light on the 
neurone and its relations to the rest of the nervous system, 
that you will some day burn with desire to know them and 
their great work and to know the work of many others 
among, foreign and American authors. 

As the time passes, during this course, you will become 
familiar with other great names in neurology than those I 
have mentioned and learn a little of their contributions, 

*Tht Nervous System and Its Constituent Neurones, New York. 1899. 



16 

but with whose entire work you will not find time to 
become thoroughly acquainted during this session or 
even during the time you are in college. Should you 
find opportunity, however, in connection with our present 
theme, the neurone, either now or during your vacation, 
you can read with profit the history of "The Development of 
the Neurone Concept, the Neurone as a Unit, and the Histo- 
genic Relations of the Neurone" in the first five sections of 
Barker's great work to which 1 have already referred, making 
over three hundred pages of solid reading, every line in- 
structive, in this more than one thousand page volume of 
neurological fact and concept. Great work and great names 
are of record there, besides those already referred to; 
Von Gudden, Von Lenhossek, Flesh, Flatau, Sandovsky, 
Biedl, Bernheimer, Marchi, Berkley, Marina. Names whose 
work will endure after we shall have passed away; names 
that will abide with that of the distinguished author who 
records their work, for Time to place on pages of im- 
mortal fame. 

THE NEURONE DEFINED. 

The term neurone has largely supplanted the term 
nerve cell, or ganglion cell of the older, but yet quite recent, 
neurological nomenclature. A neurone, or as it is still 
sometimes called a neuron in the neurocytological nomen- 
clature and cytology or cell study of the present time, 
is a nerve unit. This nerve unit includes the nerve cell 
as yet described in most of your anatomies, its processes, 
collaterals, and terminations. For all practicable purposes 
you may still consider it a cell, a nerve cell, (vcvpov-\- 
kvtos) with the exception that it is not a network of 
nerves in the older sense, sending out prolongations that 
blend and intertwine with contiguous nerves, but a nerve 
mesh, or neuropilem (vcvpomtefi) distinct and disconnected 



17 

but capable of communicating its influence by contact, as 
one student in the class may impress another by close or 
remote contact without grabbing him by the throat or in- 
tertwining his fingers in his hair; or as bricks standing in a 
row. Start one and they fall one after another. While the 
old nerve net of Gerlach is yet described in some of the 
books you have but lately studied, and the nerve mesh has 
taken its place, the ganglion cell, with its axis cylinder pro- 
cess, will still interest you as a fact in neurology, only 
differently and a little better understood as a nerve unit. 

The neurone has dendrites; cellulipetal or centripetal, 
the equivalent of afferent prolongations, and cellulifugal or 
centrifugal or efferent processes or neuraxons, conducting in- 
fluences away from the cell body. With reference to the 
center of the neurone, therefore, the dendrite corresponds 
in function to the afferent nerve (ad and ferre, to carry to) 
of the spinal cord, while the axone or neuraxone corresponds 
to the efferent (ex and ferre, to carry from or eo t 1 go forth). 
The dendrites receive, and the axones carry, impression 
to and impulses from, the center, i. e. 9 to and from the 
neurone or nerve center cell. 

There are some exceptions to this law, as in those 
dendrites from which an axone occasionally takes its origin. 
An example may be found in the retina, but you need not 
concern yourselves about this just now; you will not be asked 
about these exceptions as they may be found in the amac- 
rine cells of the retina, etc. The rule is general, but not 
universal. Barker would leave the question open, but some 
questions about which savants may wrangle must be closed 
to teachers and tyros as we approach the close of this lec- 
ture. 

Here again you may for next summer's diversion, after 
this course is over, take with you the books of the neuro- 
physiological masters when you go fishing, or retire to the 



18 

shade of the trees to read and study out this intricate sub- 
ject between nibbles and bites on your hook, for one of 
the great masters to whom 1 have already referred 
has said that "at present we are well acquainted with the 
evidence of the passage of impulses in neurones in one 
direction only, does not exclude the possibility that we may 
at some later time become cognizant of the facts which may 
demonstrate the conduction of .impulses of some sort in the 
opposite direction, especially as physiological experiment has 
shown that impulses artificially exerted in nerve fibers travel 
in both directions from the point of stimulation." (Barker 
p. 274, ed. 1899). Here then, is a chance for you to 
become famous while you fish, by working out the unsolved 
problems of nerve conduction, vicarious, alternate or sub- 
stitutive nerve function, etc. The vagus nerve appears to 
have both afferent and efferent function. You may yet be 
able to demonstrate that the first or incoming, and the second 
or outgoing, impressions go over the same nerve strands. 
If you do your fame will be made. 

Neuraxon or neurite means the axis cylinder pro- 
cess of a neurone, the principal projecting part of the 
neurone. Schafer also called it a neurone. He gave the 
name dendron or dendrite (&vfy>w, a tree) to the shorter 
protoplasmic branchings or prolongations or processes of the 
neurons. He called the dendron, a dendrite. Neuraxoris 
vary in length from a millimeter or less to many centimeters. 
The largest neuraxons are in the pyramidal tract, measuring 
nearly a hundred centimeters. If you have time between 
the lectures or during your vacation you may consult with 
signal profit the first chapter of Mills* on the subject and 
more recent American authors. You will see in the very 
beginning of his book, on the first page, a cut taken from 

*The Nervous System and Its Diseases by Chas. K. Mills. Llpplncott & Co.. Philadel- 
phia and London. 



19 

Quain's Anatomy and to be found in some other anatomies 
and neurological treatises to which 1 shall often refer arid which 
1 shall several times draw on the blackboard during this course 
of lectures, as 1 do now, with various modifications. I am ac- 
customed from previous and consequent automatic habit to refer 
to the cerebro- spinal or encephalo-spinal axis, but 1 do not so 
often use the newer and shorter term neuraxis. The term 
neuraxis does not locate itself with the defined expressiveness 
(though it is shorter) of cerebro or encephalo-spinal axis, but 
is quite as expressive when you understand it. Both terms, 
however, mean the great brain and spinal center of the 
great neuraj organism of the body, an organism as omni- 
present in the animal mechanism as the almost everywhere 
to be found blood vessels. The neuraxis is the axis for 
the entire nervous system. Axis is the Latin for axle as 
you know and means a thing about which something else 
revolves. It means here central or pivotal, as you have, all of 
you, learned in studying physics and anatomy. In your anat- 
omy of the skeleton you will remember the second cervical 
vertebra above which and around whose odontoid process, 
the atlas, which holds up the cranium as the fabled Atlas 
did the world, and around which the atlas and the super- 
imposed cranium, rotates. The term neuraxis, figuratively, 
but quite appropriately, answers for cerebro -spinal axis, 
because the rest of the nervous system proceeds from and 
figuratively revolves around it. Neuraxon, so like it in sound, 
means the axis cylinder process of neurone. It is a very 
essential part of the nerve cell or of the neuron, as you will 
see as we proceed. 

You see this little Greek word vcvpov, with its con- 
tractions neu t neur, neuro, etc., is constantly recurring in our 
precursory incursions into the interesting domain of 
neurology. Term after term will come into use like 



20 

neurectomy, (vcOpov, a nerve, and r^w.v % to cut) nerve 
cutting, a thing the surgeons are sometimes too prone to 
do, (as neurologists sometimes think) before the neurologist 
has exhausted his resources or without consulting the 
neurologist as we sometimes think they should, and a thing 
they often do to our great relief and to the relief of the patient 
as well, sometimes before neurotheraphy has been thorough- 
ly tried as we think we know best how to try it, as in 
that formidable capital operation of the nervous system 
Gasserian Gangliectomy or Gasserian neurectomy or neuro- 
tomy, the cutting out of the ganglion of Gasser from the 
under surface of the brain, an operation which only skilled sur- 
geons should undertake after wise neurological counsel. You 
will learn more about this subject when we come to discuss 
trifacial neuralgia or neuralgia of the fifth nerve (from wJpWi 
a nerve, and aAyos, pain) sometimes also called prosopalgia, 
from prosopon, the face, and the Latin algia, pain, a shoot- 
ing pain involving the branches of the fifth nerve or three 
branch nerves of the face and its ganglion (Gasserian); a 
nerve which Sir Charles Bell, a great Englishman, once at- 
tempting to operate upon including with his knife the 
seventh nerve, and thus producing surgically a form of that 
characteristic facial expression palsy which now so univer- 
sally bears his honored name, now so interesting to neu- 
rologists. 

Neurilemma (A-c^a?, sheath or husk, sheath of the 
nerve, epinurium, «ri f upon, and wV, nerve), h/eurility 
signifies nerve power or power of nerve life, impulse, per- 
ception or power to muriate, if by warrant of philological 
analogy we may be permitted to use such an expression. 
In this connection there is one term which, by contrast you 
will remember, after 1 mention it, as having no just warrant 
for its derivation, a gelatinous, bad-smelling product of 



21 

animal or fish putrefaction, a non -poisonous ptomaine when 
unmixed with other ptomaines. This is called neuridin, 
which I consider an unfortunate misnomer, for there is 
little or no nerve in it, though the vagus nerve goes to 
the viscera whose decomposition sometimes causes it, and 
nerves go to the muscles whose decay may engender it. It 
and its poisonous fellow ptomaine called murine, obtained 
partly from the same source, which acts so much like curare 
on the motor nerve terminals, causing dyspnoea, convul- 
tions and death, ought to be substituted by more suitable 
terms. Neurine should pertain to the nervous system only 
and not to products of either poisonous or non -poisonous 
decomposition of fish, fowl, flesh or viscera. Sheppard has 
used and applied the term more appropriately, though in an 
unusual way, to the gray matter of the layers of the cere- 
bral hemispheres, which he called the neurine batteries of 
"the brain. 

There is also the term psychosis, from ^hwi, the soul, the 
rnind, meaning a disease of the mind usually functional, and 
sycosis, from <tvkov, a fig, used to designate a disease of the 
hair follicles. The dermatologists should give this term up to 
us. Everything should make way for advancing psychiatry 
and its designating terms. 1 do not like terms that confuse the 
student of neurological science and make his task of acquisi- 
tion more difficult than it is. My business is to simplify 
your work and clarify your course through your curriculum. 
The ponderous volumes written up to date and by meritorious 
authors on neurology and psychiatry are paralysing enough 
to contemplate, but if you will listen to me faithfully and 
observe the illustrations 1 give you during the session, I will 
elucidate the subjects upon which they treat to the best of 
my ability, so that you may comprehend them when you 
consult the great text- books of the great masters and enjoy 



22 

the leisure of the early days of your practice and the coming 
decades of your professional career in mastering them. You 
are expected to master the salient points only and not the 
entire science of neurology during your undergraduate life. 

We expect to make you successful students during your 
nmi-.r in neurology and not expert masters of the subject; 
In Maze .1 i Irar pathway and clear out the underbrush of 
Mm- Ihhltly wooded and tangled forest, so that the light will 
fchihi- HiUMiuli it, and to direct you aright so that you may 
iMVfhr alone and better, when without us and at your 
Iriaiiifr, 111 delighted companionship with greater leaders of 
iMii i^ieal m ience and art. There are great names in neu- 
Hiliiyv, greater than the name of Agamemnon; great names 
oih' t-, as well as before that great Agamemnon in neurophys- 
iology, (Jamie- Bernard. Immortal names whose memories 
you will revere, and yet living names whom you will honor, 
f Jiahiii, Claude-Bernard, Marshall-Hall, Beard, among the 
immortals abroad, Brown-Sequard, Seguin, Hammond, Ami- 
don, Amariah-Brigham, Benjaman Rush among our own 
honored dead and hosts I cannot now recall, and Virchow, 
the venerable chief among the yet living. May he live for- 
ever. You may be surprised that I mention our Benjamin 
Rush as chief among my gallery of immortals, for he was 
only an American, and great names in American medicine 
are not yet in good form. He lived and died on the wrong 
side ot the Atlantic, like McDowell and Morton, and yet 
awaits a place in Fame's Pantheon. But scan his works 
and words well and you will see that even he, an old-time 
American doctor, deserves a place, it not in the temple of 
modern psychiatry, yet upon Fame's eternal camping ground. 

Some day in your time the world will applaud more 
than now the merits of Benjamin Rush. He was a neuro- 
logical giant in his day. He saw things in psychiatry with 
astonishing precision. 




Bourgery's outline lateral view anatomical diagram of the cerebro- 
spinaUaxis or neuraxis, from Quain's anatomy, showing the cerebro-spinal 
cavity from the top of the brain within the cranium to the end of the spinal 
cord, Cauda equina and coccyx. F, T and O are the frontal, temporal and oc- 
cipital lobes of the cerebrum; C, P and Mo are the cerebellum, pons Varolii 
and medulla oblongata; M and Ms show the upper and lower extremities of 
the spinal cord; Ce, the cauda equina at the lower end of the spine be- 
ginning with the last lumbar spinous process; V, ganglion of the fifth nerve 
or the trigeminal, or ganglion of Gasser with its three branches faintly 
shown; C L shows the first of the spinal nerves or first cervical coming 
out under the occiput, and CVIII is the last or lowest cervical ; DI is the 
first dorsal or thoracic and DXII is the twelfth or lowest and last dorsal. The 
first sacral nerve begins at Si; Sv is the fifth sacral; S is the sacral plexus 
and Col is the coccygeal nerve. 



CHAPTER II. 

THE NEURONE AND THE NERVE CELLS: THEIR COMPOSITION 
AND CHARACTERISTICS. 



Notwithstanding the delicate structure of the higher 
functioning neurones, their morphological or shape differences, 
corresponding to their grander activities in the scale of 
being, eminent physiologists tell us that these high power 
neurones, like other cells of the body of lower anatomical 
station and physiological dignity, possess protoplasm and nu- 
clei, the morphological characteristics of which, so far as can 
at present be unraveled by the highest powers of the micro- 
scope, would scarcely seem to differ from those of the cells 
of less noble tissues, to account for their greater dignity. 
There are, nevertheless, and there must be, certain deli- 
cate differences in the neurone structure, since structure 
and function throughout all nature are correlative, like the 
varied mechanical adjustment of varying movement, which, 
though no eye has yet seen and no glass can now reach them, 
must yet some day by more delicate means of research than 
are now at hand be brought to light, by sight of science, just 
as we know in daytime there are stars above us, though we 
see them not save by the revelation of astronomy. In fact, 
notwithstanding the remarkable uniformity in type of the 
nerve cells in the most diverse parts of the central nervous 
system, Barker assures us that the neurones are not every- 
where so similar as to be practically indistinguishable from 
one another and cites a wealth of morphological peculiari- 

[23] 



24 

tl*n revealed specially by the research methods of Golgi and 
fjhrllrh, which neurophysiologists were formerly unable to 
obtain. Barker Hives differences of internal structure of 
different cell groups recorded by the method of Nissl, which 
he regards as of equal importance for purposes of classifica- 
tion to the external form from relations discovered by 
(mlgi't* stain, and "Barker knows his business" as well as 
f#olgi and Nl e.l, Held, Apathy and Foster, or any other in 
tie- profession's galaxy of cytologic stars. "There are 
many neurones which from the appearance of. a single 
example stained black with silver, permit an absolute decision 
as to their smut e M and Barker here mentions the cells of the 
sensory ganglia, those of I'urkinje in the cerebellum, the 
pyramidal tells of the cortex and certain cells of the hip- 
po* jimpus. Some nl you may be able to verify in the 
hi"l'»f/i<al laboratory before your studies here are ended, 
the truth of this verifiable statement. You must not stop 
win-re I leave you, but press on beyond to the entrancing 
neiip/auatomii al and neurophysiological landscape, now 
pomleil out and with wider and ever widening microscopical 
vision, as yon glow in knowledge of the wondrous and 
'ompll'ale met danism of man's marvelous nervous system, 
fill yon pass beyond the horizon which now apparently, but 
not in reality, bounds your progress. There is light for you 
in the far beyond, and in tin* sweet by and by, but we have 
not time to eo their now and many suns must rise and set 
hefoie you may lejii h the glorious goal. 

After the bird's-eye view 1 have given you of the 
beautilul beyond opportunities of investigation, it will in- 
terest you just now to know that you are not expected to 
know all, as only the great masters see the entrancing field 
of cytology, (for that is what it is called, kvtos, a cell, Aoyos, 
a discourse), in order to get your degree from his college, but 



25 

you will be expected to know something of what the master 
minds are doing, and a good deal of what we show you, 
that you may wisely follow them after you shall have 
learned to walk and not creep in their cytologic footsteps. 
The cytologic way in physiology will interest you quite as 
much as the Milky Way may have entranced you in your 
preparatory college survey of astronomy, for it is strewn 
with marvels of light on the wondrous life and potencies of 
living animal matter. Cytology is a study of the neurones, 
or cells, and astronomy is a study of the stars and, used 
like astronomy in its broader sense, the study of the 
neurones is a study of all that pertains to the cells, or 
neuronomy, if the philologists and the linguists will permit 
the term, in the sense that it means a grazing among the 
nerve cells and their belongings. The neurone then is the 
complete nerve cell or ganglion cell, embracing the nucleus, 
nucleolus, axis cylinder process, or axone and dendrites 
(all processes, collaterals and terminations) grouped into 
a nerve individuality or independent unit. The neurone 
does not, through prolongations, intertwine with processes 
from neighboring cells; it does not anastomose like 
terminals of the vascular system as in the capillaries. It 
is a separate and distinct personality, so to speak, capable of 
coming into contact, but not of mixing or interlacing or merging 
with other neurones so as to lose its individual identity. It is 
not a mixer, but stands upon its own individuality and here 
are some examples for your inspection of the nerve units 
which we now call neurones. With this wider and more 
definite understanding they might as well have been called 
cells as heretofore, for they are the same cells known 
before, only we have become a little better acquainted with 
them and know their nature, relations, and distinctive in- 
dividuality more familiarly, and talk of them in a broader and 



26 

more inclusive sense. When we say neurone, we mean all 
that pertains to the cell; its nucleus, nucleolus, its axis 
cylinder process or neuraxon, the dendrites, the myelin 
sheath of its collaterals and its split up end brushes 
or terminal arborizations. The neuraxons and dendrites 
of different cells come together, but do not anatomically 
anastomose. The neurones mingle but do not mix, 
they associate but do not join together, they are well 
acquainted with each other, especially the psychic neurones 
of the several layers of the gray cortex of the brain, and 
they are of the same blood as their neighbors, but they are 
neighbors only, units of adjoining families, not married to 
each other. They are separate and distinct but yet intimate 
friends, working side by side, often in the same nerve center 
to the same neurophysical or neuropsychical purpose. 

The neurones, like cells everywhere, reveal under the 
microscope evidences of change in composition from excessive 
and toxic impression. Dexterity and disintegration in 
exercise, waste and work, rest and repair, are correlative 
terms in the nervous system, as in the muscular. The 
microscope shows this among the muscle cells, as it 
does the ravages of disease, among the neurones. 
Micro- physiologists have, by diligent labor, made brilliant 
discoveries concerning the peripheral and central nerve 
cells. The neurones of the cerebro-spinal nerve centers 
and the peripheral nerves have been examined before 
and after exercise, before and after alcohol and mer- 
cury, nicotine, lead, phosphorous, arsenic, strychnia and 
various other poisons and after the withdrawal of the blood 
supply from the neurones, as in anemic neurasthenia and 
before, which experiments have thrown much light on the 
beginnings of disease, not only in the neurones, (or entire 
nerve cells) but of disease found in the neurones in con- 



27 

nection with persons who have died of other than recognized 
nervous diseases. 

Neurones directly or indirectly suffer in many diseases, 
probably in all, as we might learn through more ex- 
tended research. So that all diseases may interest you 
in the studv of the normal and abnormal nerve cell or 
neurones. All acute and chronic degenerative processes in 
the nervous system appear to begin or end in the involve- 
ment of nerve cells. You will learn in the biological 
laboratory something of toxic cells, their chromatolysis, 
cell swellings and cell shrinkages, of remote and central 
degenerate reaction from cell or peripheral nerve injury, the 
effects of infections and intoxications, chronic and acute, 
from disease, autotoxins from within, or poisons from with- 
out, or from intense heat and the restitution which follows 
the restoration to normal temperature. We cannot here 
discuss these matters in extenso, but a hint to the wise is 
sufficient. You will not need to seek diversion in novel- 
reading or the theatre. You will find it in the study of 
the neurones, beyond what we can teach you in this 
amphitheatre and there discover how much stranger is 
scientific neurological truth than any fiction. 

The composition of the cell body or bulb of the neurone is 
much like the white of an egg and is called protoplasm, and 
in cytologic technicality cytoplasm. All nerve cells or neurones 
have a nucleus and the nucleus a nucleolus or ultimate 
or lower nucleus. 

The neurone is not throughout a homogeneous sub- 
stance, as you are ready to infer from its divisions for 
functionating purposes, since modifications of structure, in 
the nerve cells as elsewhere, as we can discern by analogical 
reasoning if not by search of scientific resource, vary with 
differences of function. A viscid-like plasma is thrown around 



and between the net-like work of granular fibers, which 
mal<e up the body of the neurone (neuroglia). The neu- 
rone has within it chromophile granules, so-named because 
they may he stained by aniline, silver and other color agents. 

I:a< hone of tin* many meritorious text-books on neurology 
*.,m< tinned by this chair in the annual announcement has 
•.oiiir <>i several distinctive features of interest in text or 
illir.ti.ttnm, hana, Mills, (iowers, Ross, Dercum, Church and 
ivieiMin, Potts, <iray, Hamilton, Hammond, Hirt, Ranney, 
SI. ii i, besides the Huropean authors which some of you 
have in your mother or acquired European language. Each 
and all ul them will enlighten you further than I can today 
by test < it illustration, or both. Many of them have illustra- 
tion . that will aid you further than 1 can, by taking your 
Iimh' dining the hour to show you under the lens or on 
Km Imaid. Reler to your text-books for the picture paint- 
ing il foi uniliiui', else, ol any part of my subject which I 
m.iy lift make plain to you during the lecture hour. 

^i.u oltm hear it said that * 'life exists in its simplest 
I'm 111 111 Up- «ell, M that organs are but aggregations of cells, 
and .uiiiii.il nii'.amsiii hut an aggregation of organs intimately 
,i . .o. i.iti-il jikI lelated, and that life like "light and sound 
an- im'mIi •, nt motion," yrt the neurone is more wondrously 
« oinplH ated physiolngirally than it looks and as we are yet 
in l<ain, pmhahly through higher and greater powers of 
mi< roM hetnii al research. Just what chemistry is constantly 
tea* hing us in regard to its so-called chemical elements 
and some of its so-called simple compounds like N O 2 , 
the air we breathe, for instance. 

I hiring your leisure hours of relaxation from the severe 
studies of your college curriculum and in your vacation you 
may find profit in scanning, if you have not the time to 
read closely, some of the leading medical journals of the 



29 

day. In them you will find articles, editorials and para- 
graphs that will impress your work on your minds and help 
to give you valuable stimulus and incentive to study. 
Apropos of our subject is the following, reflecting current 
professional opinion respecting the value of the study of 
the neurones or entire nerve cells":* 

"The beginnings of disease must necessarily consist in 
undiscernable alterations in cellular structure and function, 
and it is probable that changes of this character underlie 
the so-called functional disorders; namely, those unattended 
with evidences of structural or organic lesion. Recent ad- 
vances in staining methods have, in fact, helped to disclose 
minute changes in cells subjected to various morbid in- 
fluences, and thus lend support to the view briefly ex- 
pounded. Such alterations in cellular nutrition may result 
from the action of substances normally generated within the 
body, but now produced in excess or in deficiency, in con- 
sequence of some derangement in metabolic equilibrium, or 
in themselves abnormal, or introduced from without in con- 
nection with infection or intoxication. 

Bearing upon this subject, Dr. Theodore Kiingmannt has 
recorded the results of some observations on the cells of 
certain algae and protozoa. It was found that a variety of 
changes could be induced by artificial means: (First,) 
Changes identical with the physiological appearances 
occurring in the cells when they die gradually from natural 
causes; (second,) changes of a purely chemical character; 
(third,) changes of a pathological nature due to toxic sub- 
stances — the results varying with the intensity of the 
operating influence. In one series of observations metallic 
substances were employed to induce the changes described. 



•Conclusion of an editorial In the New York Medical Record, April 20, 1901. 
XAmtrican Journal of Insanity, vol. Ml., No. 3, p 519. 



30 

In the second series Mood serum obtained from patients 
suffering from various forms of so-called functional, nervous, 
and mental disorders was substituted. Analogous results 
were obtained in both series of experiments. A great variety 
of pathological conditions was found in the ganglion cell of 
rabbits and guinea-pigs treated with injections of toxic 
serum in varying dilution, the form of chromatolysis (cell 
coloring) varying with the strength of the serum and the period 
of its activity. The use of blood serum from healthy in- 
dividuals, on the contrary, yielded negative results." 

You cannot keep yourself in normal touch with the 
advance in your profession without a few representative 
periodicals for daily reference and there is a profusion of 
good journals in this country. Take a few choice ones and 
you will not forget what you have been or shall have been 
taught in this college and with the help they will give you, 
will constantly add to your store of medical knowledge. 

Morbid changes in the neurones have been found to 
end in fatty degeneration. Changes in the neurones of the 
gray matter of the brain have been found in insanity, in 
acute delirium, delirium tremens, in paralytic dementia, 
hypothermia or extra high-grade fever, in the bubonic 
plague, in typhoid fever, in infectious maladies and poison- 
ings and as 1 have already stated, in bromide of potash 
poisoning, besides the other drugs already named. In 
uremia, in multiple sclerosis, in chorea, in tetanus, ataxia, 
lateral sclerosis, poliomyelitis anterior, etc., and in the 
peripheral nervous system, as in polyneuritis, or inflammation 
in many nerves, neuralgia, that painful paroxysmal affec- 
tion of the peripheral sensory nerves, as of the face, above 
the orbits, about the mouth and jaws, in the tongue, etc. 

Bevan Lewis' and Ford Robertson's illustrations of dis- 
eased neurones will instruct you much. One thing about 



31 

the neurone's pathology I wish to impress here, viz: When 
the nucleus of a neurone is diseased it seems to die, while 
its neuroglia, neurites or dendrites may become diseased 
and yet may recover. But disease damage done to the 
proliferating neurites or dendrites or neuroglia also affect the 
function of the neurone body. 

The loss of the customary peripheral, afferent or sen- 
sory impression has been shown to cause changes in the 
central spinal cord neurones and the cord cell changes also 
contribute to make those departures from the normal ana- 
tomical and physiological state of the neurones in the cerebro- 
spinal axis or central nervous system, the peripheral or 
sensory motor nervous projection system and sympathetic 
nervous system. This we call the pathology of nervous 
disease. 

Pathology in the nervous system, or neuropathology as 
elsewhere in the animal organism, is abnormally changed 
anatomy, and disease, as we see it ante-mortem, is 
abnormally changed physiology. It is physiology perverted 
by pathology. After the death of a part it is pathological or 
necroscopic or morbid anatomy. Disease of the nervous 
system is pathology of the nervous system in action. Its 
structural causes and results make the pathology, its 
functional results make symptomatology. Morbid anatomical 
findings may also be a cause of other disease, than 
that diseased action which produces them. The real disease, 
with its strictest definition would be in the nervous sys- 
tem or elsewhere, that is, the altered molecular activity 
that leads to the changes in the cells producing the changes 
in the organic structure, causing the organic functional 
changes or symptoms. This is true of the nervous system 
as of every other part of the body. The microbe or bacillus 
or materies morbi or psychic impress, changes the molecules 



32 

that change the cell, that change the motion, that change the 
function of the changed frame that nature built, as we see 
it in disease. That change, when the nervous system is 
specially involved, we call nervous disease. 

The central neurones and the nervous system are subject 
to slow chronic inflammation associated with syphilis, tuber- 
culosis and the poisons already mentioned and by auto-toxic 
or toxic products generated by and within the body. Be- 
sides urea, already mentioned, which may so impress the 
psychic neurones and the vaso- motor centers of the brain 
as to cause the unconsciousness of coma and may im- 
press the psycho -motor centers so as to cause spasms and 
convulsions, the body -generated poisons of gout and rheuma- 
tism, (uric and lithic acid) and the sugar of diabetes may 
engender changes in the neurones or proceed from changes 
in the neurones of the nerve centers as they do in 
other tissues of the body. Thus you have diabetic 
coma as well as dropsy which may be caused by irrita- 
tion in the floor of the fourth ventricle whence the great 
vagus nerve arises, along with other cerebral nerves, as 
well as by changes supposed to primarily take place in the 
liver or elsewhere. The physiologists have generated gly- 
cosuria by mechanically irritating the tloor of the fourth 
ventricle of the brain. They have also induced it by fret- 
ting dogs, by keeping them confined in sight of other dogs 
at play. As uric acid irritates the muscle and joint tissue 
into inflammatory action, as you see so fatally illustrated in 
the acute myocardites and pericardiac inflammatory effusions, 
that impede and arrest this vital organ's action, so it may 
locate in and similarly damage the delicate structures of the 
brain, as it so often d«»es the muscles and joints, changing the 
anatomical and physiological conditions of the neurones and 
connective tissue or neuroglia into pathological states andsim- 



33 

ilarly involving the peripheral nervous system, as in the rheu- 
matic and other auto-toxic neuritides or inflammatory states 
of the nerves from self- generated or body-generated poisons 
or from poisons from without the system as alcohol, arsenic, 
lead, etc. This autoxicity might be called the sub-conscious 
suicidal tendency of the body. It is in some cases termed 
a diathesis, which is a congenital or inborn or very early 
acquired aptitude of the system to actively take on, under 
slight external influence, certain morbid states. Diathesis is 
from T10CWU, to place, and &a, through, and thus we have the 
influence of the gouty or arthritic, rheumatic, strumous, or 
tubercular, catarrhal, haemorrhagic, aneurismal, psychopathic, 
neuropathic diatheses, etc. Toxines and habitual or occasional 
autotoxicities, influence and precipitate the development 
of mental and nervous diseases through predisposition of 
the neurones and their connections of the cerebro-spinal 
axis and the peripheral nervous system, which includes the 
the sympathetic and its vasomotor system, especially the 
latter, as when the haemorrhagic diathesis appears in disease. 

Thus you see in studying the nervous system in all its. 
cell diseases and relations, you must understand the whole 
man, for it is influenced by so much that affects the body 
in general and its diseases, as it also so much influences the 
organism as a whole and in its parts. In this vast chain 
of being, the neurones make many links and all the organs 
and viscera are links of strength or weakness. Ancestral 
organic endowments are links of direct or atavic descent, 
that go to make the chain of health or disease in the 
nervous system stronger or weaker, and knowledge, or 
lack of knowledge of these matters, will make you stronger 
or weaker as practitioners of medicine. 

The neurones are nourished by the blood, as all other 

♦Vldt author's paper on haemophilia. Alienist and Neurologist. July, 1887, and pro- 
ceedings St. Louis Medical Society, 1884. 



34 

parts of the body are, but not in the same simple way as the 
other and courser tissues. A more intimate relationship 
appears to exist. Adamkiewicz* in describing the fine 
anatomy of the blood vessels of the large intervertebral 
ganglion of the brachial plexus says: 

"The ordinary arterial capillaries give off finer capillaries, 
(vasa serosa) which are so fine as to transmit only the fluid 
•constituents of the blood and none of the corpuscles" — finer 
than those which carry only the white blood corpuscle vessels 
as those to the sclerotics of the eyeball, for instance. 
These vessels go to the neurone, spread out and envelop 
it like a glove and then narrow down to their original size 
and empty into another arteriole capillary. This demon- 
stration in the intervertebral ganglion has not been so well 
proven as yet. But Adamkiewicz reasons that the neurones 
of the cortex of the brain are similarly nourished in this 
wise. He points out that the exposed cortex is perfectly 
tolerant of a forcible stream of distilled water, which if in- 
jected into the carotid will immediately produce nystagmus, 
extensor spasm all over the body, and disturbance of the 
pulse and respiration. His anatomical argument is that 
the vascular network in the cortex, as demonstrated by the 
injection of carmine gelatine, is much closer in those parts 
of the cortex which are richer in ganglia than elsewhere, 
and concludes, "all arteries which enter the brain and spinal 
cord ot man and of animals, at least of the higher animals, 
end on the further side of the capillaiies in very fine plasma 
vessels which contain ganglion cells, in diverticular ex- 
pansions." For ready remembrance the neurones may be 
likened to little islands surrounded by water. Nature seems to 



•StMien Alle (i.tnulieniellen mil Jen BlutRifasson in Directer Verbindung Nurologische 
OntralblaU fur January. l'JHO. 

W. 11. H. Stoddard in the Journal oj Mental S./.w.v for January. 1901. goes over 
this subject in English. 



35 

love to invest them, as it does other parts of the nervous 
system, with serum. The spinal cord hangs in the vertebral 
canal, closely filling it, like a substance suspended in a bottle 
of water. The arteries of the brain have their perivascular, 
serum filled spaces, and the lymph of these perivascular 
spaces is the same as that of the ventricles and the spinal 
cord. The brain has its serous arachnoid investment and 
its serum filled ventricles, and the nerves and the neurones 
float in microscopic rivers of water, so to speak, the serum 
surrounding the nerves and cells. The subarachnoid spaces 
communicate with the fourth ventricle and they with each 
other except the fifth, and with the cord they contain the 
spinal fluid. 

The brain, spinal cord, sympathetic and sensory and 
motor parts of the peripheral nervous system have systems 
of irrigation as well as a sewage system, systems of recon- 
struction or nutrient supply and systems for waste removal, 
as other parts of the organism do (arterial, venous, 
lymphatic systems). An idea of the irrigation or nutritional 
system of the brain, for instance, may be obtained from a 
study of the circle of Willis and its distribution and from 
an examination of the fluid filled spaces around the blood 
vessels and perivascular spaces and the fluid filled spaces 
of the five ventricles of the brain and of the subarachnoid 
spaces. The illustration 1 show you here is one of the 
cerebral perivascular spaces. The walls of the arteries 
and veins of the brain cortex are directly enveloped by 
outer walls of pia mater which secrete lymph and make up 
the perivascular vessels and lymph spaces. This lymph 
contributes to the nourishment of the surrounding neurones 
and neuroglia. 



illustrating a part of the brain's irrigation system. 



fig. 2. 




The D, A, P, Hiving the memorial worJ Jap, show the relative position 
from above downward or from without inward of the cerebral minenges, dura, 
arachnoid and pia, indicated also by numbers 1, 2 and 3. Fig. 1 shows 
the subdural space, 2 the arachnoid and 3 the pia, between the layers of 
of which arc seen ramifying small vessels of the brain which branch down- 
ward to penetrate the substance of the cortex, 5, 7, 8 and 9, invested 
by delicate pial sheaths, with lymph between their walls and those of the 
vessels of the perivascular spaces 6. 



ISOLATED ARTERIOLES AND PERIVASCULAR LYMPH SPACES 
OF THE BRA1M. 



FIG. 3. 



FIG. 4. 




— An artery from the 
cortex cerebri in longitudinal 
section. Magn. 80. Numbers 
of fine fibres are seen streamiug 
into the brain-sul*tance. 




— Section from the cornu Ammonia, 
snowing perivascular and pericellular 
lymph-epacea. Stained with carmine. 
Maqn. 150.— a, Capillary vessel in a 
perivascular lymph-space; 6, pericellular 
lymph-space directly continuous- with 
the former. Two leucocytes are seen 
in the pericellular space c, and one in 
the space b. (OWtS\fcttVCc} 




FIG. 5. 



Fig. 3, isolated arteriole: Fig. 4, arteriole surrounded by perivascular 
;ces; Fig. 5, a distended perivascular space with arteriole atrophy, after 
ner Fothergill. 



NEURONES OF THE BRAIN AND SPINAL CORD. "PSYCHIC CELLS" OR NEURONES 
OF DIFFERENT VERTEBRATES. NEURONES BELOW 
INVOLVED IN DISEASE. 
FIG. 7. FIG. 8. 




A I 



FIG. 11. 



FIG. 6. 



FIG. 9. 



Fig. 8. A pyramidal cell or central neurone from the cortex of the cere- 
brum with the dendritic ramifications (dendrites, protoplasmic process). 
Each process gives off a great number of bud- like branches. The nerve 
fiber of the cell, or axis cylinder process is designated ax. The terminal 
fibrils of the axis-cylinder process go on some distance from the cerebral 
cortex to other portions of the brain or cord, where they surround the den- 
drites of a ganglion cell. This neurone begins and ends within the central 
organ, and is termed a central neurone. 

Just below Fig. 8 is (Fig. 9) a ganglion cell with its dendrites from the 
anterior horn of the spinal cord; among its ramifications are seen the ter- 
minal fibrils of the nerve fiber belonging to the central neurone. The axis 
cylinder process (ax) emerges from the central organ and passes to the soft 
parts In the periphery. The entire neurone is, therefore, called a peripheral 
neurone. 

The third illustration below (Fig. 10, from Ford Robertson, Plate xxix) 
shows in marked contrast, a pyramidal nerve cell (neurone) of the 
cerebral cortex from a case of chronic tuberculosis of the kidneys and blad- 
der, showng varicose atrophy of protoplasmic processes (dendrites). Here is 
an intra-neural change dependent upon the extra-neural disease tuberculosis. 
These changes in the psychic neurones account for some of the peculiar 
psychic symptoms of tuberculosis. 

Immediately to the left of Fig. 8 is an illustration (Fig. 7) from Ramon 
y Cajal of the "psychic celP' or neurone in different vertebrates used for 
comparison They show also the remarkable morphological resemblances, 
considering the apparent and generally believed difference in psychic 
manifestation of these neurones of mental function in animals and man. 

The upper series of cells shows the "psychic" cell in different verte- 
brates: A is the psychic neurone of the frog; B, of the newt; C of the 
mouse; D, of roan. The lower series show the stages of growth of a single 
neurone; a, neuroblast with axis cylinder process just commencing; b, 
panicle commencing; c, panicle and axis cylinder process more advanced; 
d, collaterals of neurone or axis cylinder appearing; e, collaterals of cell 
body appearing (Ramon y Cajal). 

Underneath this illustration from Cajal is an illustration (Fig. 11) from 
Ford Robertson, designed to show the neuraxone or axis-cylinder process of 
a cortical neurone from a case of exophthalmic goiter, a nervous disease 
in which the sympathetic nervous system is believed by most authors, to be 
chiefly involved, a vaso-motor and trophoneurosis. 

Compare its appearance with the proliferations of the pyramidal cortical 
neurone (Fig. 10) affected with tuberculosis beside it already referred to, 
showing the varicose atrophy of protoplasmic processes, connected with 
tuberculosis of kidney, etc. 

Fig. 6 shows a normal neurone. 

Illustrations of other neurones will be shown later. 



CHAPTER III. 

THE NEURONE AND THE NERVE CENTERS, CONTINUED; THE 

NEURONE THEORY, ASSOCIATION NEURONES, 

PROJECTION FIBERS, ETC. 



Remember the illustration of the standing bricks in a row 
starting to fall atone end. When first the end one falls toward 
the others each falls successively in its turn after the preceding 
one and communicates the impression it has received to its 
adjoining fellow, it in turn communicates or passes on the 
impression it has received to the next as in the blocks 
before us. This is the way the neurones act toward each 
other. This is the philosophy of the neurone theory. 

The neurones are anatomical units with an independ- 
ent, yet communicable function, like the students in this 
great audience. They are physiologically individual and 
independent, yet they are members of a neural community 
like the free independent American citizen who is never- 
theless so dependent upon his fellows in the community for 
his welfare that he does not seek to make a hermit of him- 
self and live alone. 

The neurones influence each other by contact but not 
by being blended with them, by contiguity and not by con- 
tinuity, as Doctor Charles Potts has so aptly expressed it 
in the excellent little student's manual some of you carry 
to the class room with you with my approbation. The neu- 
rones wait on each other, attend to each other's impressions 
and wants in a manner. They are pretty closely related, 

[36] 



37 

engaged, but not married in indissoluble union of function. 
Yet they are very nearly so, for the destruction of one or 
more of one group or nerve center in the economy may 
materially influence the welfare of the other contiguous 
neurones. 

A community of interest pervades certain groups of neu- 
rones in the brain or spinal cord, which make up nerve 
centers. According to location and description, these centers 
are called cerebral nerve centers, spinal nerve centers, 
cerebrospinal nerve centers, ganglion nerve centers, psychic 
or mind impression and expression nerve centers, motor or 
psycho -motor nerve centers or the centers of cerebral locali- 
zation where motor impulses arise in the brain or cord and 
go from them. They are sometimes called also kinesodic 
centers. There are also sensory centers of the brain or cord 
where sensory impressions are received and sent on to higher 
centers or across the spinal cord to be there acted upon, 
and transformed into motion in the anterior horns of the spinal 
cord. The latter are called aesthesodic centers and the 
nervous mechanism that receives these impressions has 
been called the aesthesodic system. This system is made 
up of the different sensory nerves and their receptive 
centers as in the posterior columns and root zones of the 
spinal cord, as the kinesodic or motor nervous system 
is made up of the different motor nerve centers and 
nerves leading from the centers of the anterior columns 
of the cord, the anterior horns or cornuas and the psycho- 
motor areas, grouped chiefly about the Rolandic area 
of the brain. 

PROJECTION FIBERS, ASSOCIATION CENTERS, TRACTS 
AND COMMISSURES. 

In your study of the coarse anatomy of the brain in 
the dissecting room you learned about the brain's great 



38 

commissure, the corpus callosum and the lesser commissures 
of the third ventricle and about the conducting strands 
of the great corona radiata, etc., and from there downward. 
These, you discovered, connected one portion of the 
cerebral structure with another. The great corpus cal- 
I'sium connected the two lateral hemispheres, its surface 
forming important landmarks and points of departure in our 
own dissections, the anterior cerebrals reflecting over 
it in front the callosal marginal convolutions superimposed 
and the centrum ovale majus coming into view as we cut 
away, on a parallel line, the convex gray cortex convolu- 
tion area, including so many of the motor centers above, and 
into which corpus callosum, we made Hogarth's line of 
grace and beauty, and brought into view those wonderful 
centers of the brain, the lateral ventricles, in which we saw 
the great basal ganglion, the tenia semilunaris, the cornua 
ammones, the pillars of the fornix, the fornix itself and the 
tela choroidea, the velum interpositum and between the lateral 
ventricles the fifth ventricle, away anterior, and intermediate 
the third, with its three commissures, downward and posterior 
the fourth ventricle and between the fourth and third that 
Hen with the long name a tertio ad quartum ventriculum, and 
the cerebellum above and behind the medulla after we had cut 
away and lifted up the whole corpus callosum as I have 
done today. 

These commissures are connections and are called com- 
missural or connection fibers, but the brain has others 
which are especially called association fibers. They are 
similar to what you are familiar with in some of your 
plates showing the corona radiata. Some of them are dis- 
cernable with the naked eye or a pocket lense, others 
are more or less microscopic, just as some of the fibers of 
the internal capsule are, though you may discern them in 



39 

the aggregate. They connect convolutions and areas of the 
brain,, fronto- occipital, fronto -temporal and occipito- lateral 
and nearby convolutions. 

This great family of neurones compacted into brain 
mass and lying in close proximity to each other in contig- 
uous neighborhoods occupying so much territory, must have 
means of communication. These the cerebro- physiologists 
have named after Fleschig, projection tracts, and they must 
have centers for collecting, coordinating and elaborating im- 
pressions conveyed to them by the association tracts and 
these centers are called association centers. In the conscious 
intellectual or psychic areas of the brain the process is called 
ideation, reflection, ratiocination, cerebration, thought, con- 
ception, etc. When this association, elaboration and coordi- 
nation takes place unconsciously, the process is Called 
cerebral automatism, as in sleep, dreams, and if accompanied by 
sleepwalking, somnambulism, or if done by the will of another, 
hypotism or somnavolism as I have termed it, which 1 have 
defined to be an absence of the normal will by induced 
sleep. Learned psychologists speak of these states as 
states of subliminal consciousness. If it takes place in the 
course of a fever or a toxic state of the blood or of a dis- 
ease involving the integrity of the psychic neurones and 
their power of normal association, the condition is called 
delirium or insanity. If the function of the association centers 
is overwhelmingly, completely suspended suddenly, it is psy- 
chic or cerebral shock, coma, etc. If crippled in speech area, 
it is called aphasia, if temporarily suspended in sight area, it 
is called psychic blindness, mind blindness, selinblindheit ', the 
mind or soul blind disease. If certain other psychic perver- 
sions appear as shown by alternate emotional states such as 
laughing and crying, visions, especially of eroto-illusional kind 
and moral perversions, we are likely to have hysteria. If the 



:*j:r±T;zr:iiiT:f zr± Trjr^r-d^" a^m-r "normal, we suspect par- 
tri::- :r r zzr nti:** *: mrianzhziha. These iracts are the tela- 
rrfrr.iit x znrrii men** nr r-ars it Ae mind and these 
i-fTHirs ir.irtr: r>* zi.!»ei n*e rimr^ TrenTf* a* centers of 
tt- iii. :r ^rikT-n: rener* rr ri*in±rs re mesial action. If 
zrtt i;*nt: rcznvrz: ~?zixm:iL :s :m3*r scrtss c€ morbific influ- 
trzii* i'\± Ft ::£-.■* zrtt Z3fjz:tpzrz\\z -iarhesss or constitution 
rr^-*x::r:r.r. rr.i.: .5. trie t*rj3eanr :c rbe psychic neurones to 
ar. sr-ji.— i/y ^roe- psyche srress ml haetDOtoxines, the 
:Vr >r- t^'llt. rr.iy r:"» e Fiv t: insanity -:«■ driirium in some 
::»*—.. J: t~.r s:~.l::: :> :r. the psycho- motor area or motor 
vs:t* ::' zr.t rriir. i-ji the pvscrmc iraffpra razsttmiu is on 
•* ■ ran ::' zr>t ztzt^r^zz — either :^ These centers and motor 
vs?:-.-. :: v.e rr^ir.. we ~£y have paralysis or paralytic 
v.;-. -y ;: Ja:k>: r.-ir. :*: ^2nc isal ep:3epsy, that is f epi- 
-:;y w .:':. .:r.::ri ■:■: rer-er^! :r>:«::* .convulsive manifesta- 
• .... -. :.~t ::~ of cerebri', tremor of cerebral origin. 

NEURONES G?Ol?EL AS NEPYE CENTERS. 

Tr.-. r.e-r.r.rs :: the brain, the spinal cord and the 
;-'i-.^:.3 :' v.r svT.pitr.etij system, are assembled together in 
;■",.;,'. of s:::or. :r ::-.rr. -pities or interest, for purposes of 
-. <j*;or.. rr. .-v,r. .ar-d rr.rr.ta! impression or action, groups of 
orifro! or ir/'jiritiori ■:: restraint, sensation, mentality and 
'■motion. Ti.e-- groups are called sensory, motor, or psychic 
n-urone .enter-. Thjs we describe the cillio spinal center of 
tip* u-rvi:al or neck enlargement of the spinal cord which 
influences the widening of the pupil opposing its sixth 
nerve contracting influence, and which disturbs the pupil 
when a violent Mow is received in the hack of the neck, a 
Mow pugilists guard against, as they do blows below the belt 
win-re the semi- lunar ganglion and solar plexus are. In 
this region also are the cervical vaso- motor centers of the 



41 

sympathetic system which, when paralyzed, permit dilations 
of the brain's blood circulation vessels and cause cerebral 
congestion or fullness of blood in the head to follow, or 
when irritated only contract and cause facial and cerebral 
pallor. 

We have also the psychic centers of intellection, emo- 
tion and expression in the brain, like the speech center of 
Broca in the posterior aspect of the third left frontal con- 
volution, the psycho-motor centers on either side of the 
fissure of Rolando, the sensory centers of the cord, such as 
are involved in posterior spinal sclerosis which causes the 
patient to appear paralyzed, when he is not, and the motor 
cord centers of the anterior horns such as are involved in 
polio myelitis anterior or the essential paralysis of children. 

Then there are the auditory centers concerned in hear- 
ing naturally located in the temporal region and the 
olfactory or smelling centers singularly placed in the 
tempero- sphenoidal region instead of at the point of origin of 
olfactory nerves from its bulb and the perforated space and 
the under surface of the middle lobe of the brain, and the 
sight centers away back in the occipital lobes, as you may 
have discovered by the flash of light you saw when you fell 
backward and struck your occiput on the ice when skating 
in those happy days of boyhood, not so far away from 
you in memory as from me, but perhaps no less mentally 
vivid in me. The sight centers, diagnostically considered, 
are also in the corpora quadrigemina, the angular gyri 
and all along the optic tracts, a fact which will aid you in 
focal diagnosis of brain lesions. Then there are the centers 
of taste, facial sensation and motion and of the great vagus 
nerve going to the heart, lungs, stomach, etc., in the 
fourth ventrical, medulla oblongata region within the cranium. 

Neurones change under touch of disease and the con- 



42 



sequent symptomatic changes they will reveal to you in the 
functions of organs whose movements they inaugurate and 
regulate, either singly or as syndicates of neurone action 
organized into nerve centers, will enlist your best powers of 
observation and thought in practice to climb and later, a 
knowledge of them wilh help you to soar above the common 
herd in medicine. Fail not, therefore, to appreciate the im- 
portance of a study of the neurones. They are matters 
infinitely minute to your vision but yet magnificently grand 
for you to consider. Their study will lead you, like Provi- 
dence does all of us, in ways for the welfare of mankind 
which as yet may be "we know not of." 

NEURONES GROUPED AS NERVE CENTERS. 
FIG. 12. 




fnn.w »i*rrt M»rfl»JyfVW"t^CJVyJ 







(d'aprca Meyncrt), — Fibre* d* association. — Coupe viTiicalcetanllro- 

i ii'iirc rtu ccrvcau dii rnjrcocobtis cynomolgus. 

F, extremite frontale ; — G, extremii^ ocolpit&lo; — 11, cojmq d'Ammon; -• 

RK, IttbttlUtMgriaceerUcalc; — SH» alllon dfl rblppocamptj; , -44. Iroial&OK! 

segment du noyau laiLiculairc; — GT, avaut iuur; — Ct, queue du vorp* itrll . 

— P, pulvtnar; — corps genomlb* externa; — pv, fibn •* proprca unUfftftt denx 

drconvulutfona ; — mr, fasciculus arcualus ; — unc, faacfculm uncinate* ; — lg t 

hi longitudinal infericur; — Oa, coinmfaaure anterieure; — inf } conic- pu»- 

terieure des ventriculea tateraux. 

Antero-postertor ventrical section the brain of (cercocthm cynomoigns) 
a long-tailed ape, after Meynert, F. frontal; O, occipital; H, cornu 
Ammonis; R, R, cortical gray matter; Sh\ hippocampus; P t pulvlnar; 
Gt, outer wall; Pv, fiber propriae connecting adjacent convolutions of the 
cortex; Gs r tail of corpus striatum; arc, arcuate fibers; unc, uncinate 
fibers; Lg, inferior longitudinal fibers; Ga, anterior commissure. 



*-.•-•:* :*= jw:r^~ 5».*> »k» a» projection* 




— Cot ♦ o P e .: - . c< : e : v. p r . : ■. : e i 1 \v; \ racv do M . MeyneH * Strieker* 
linn.,'.;. h m t l|. p. -*]. t c . 24^ . K..o rep* scr.:o i:r.e coupe loopiludinaJcct hori- 
/••nn:« d* iirr- ■:it»ei::cht dj rcr\-a:idi: .v-cocebis cvno llpus. 

K. r\!r."m;*."- 'r:.r.:-j>: — 0. ri-ion occ:p:tale; — PT. e»ftc€ de la scissure de 
f\h»: ~, — 1. i^-:::a : — C*. ^i::-^:r. — T. co-ps calleux; — S, septum ; — 
O. re-:; m:?*ure antt : rv. to. 

A. r« . .r> d'Air.moa. — V. con:e ar.'.rr.iNire du \ontricule lateral; — Vf>, eoroe 
pus!»;r;c«.-c : — \ui, \tn*ric i'c du mown. — Oi. commissure morenne. — Af, 
a*jticduc. 

Li. Ln. Km. scjrmer/.f du r.».\au Kr.tica'airc; — Nfl, tcte, et Nc queue du 
noyau rand*'*. 

jh. particdela couche optiqucMtueccnavant des corps genouilles;— TA'coucbe 
optiquc, Puhinar. 



Longitudinal horizontal section of left half of brain of long-tailed ape, 
after Meynert, Strieker's Handbook. F, frontal; O, occipital region; FS, 
fissure of Sylvius; I, insula or island of Reil; CI, outer region of external 
and internal capsule and claustrum; Li, Lll, LIU, segments of cuticular 
nucleus; T, corpus callosum, anterior border; S, line of septum lucidum 
enclosing the fifth ventricle; V, anterior horn of lateral ventricle with S, 
the line of the septum lucidum between it and its opposite lateral ventricle, 
not shown in this cut; VP, posterior horn of lateral ventricle; Nc, head, 
Na, foot or tail of caudate nucleus; B, Bs, Bi, cerebral peduncle; Gi and 
Oe, internal and external knees of the corpus striatum; Th, optic bed or 
thalamus; Th', pulvinar of optic thalamus; Qu, corpora quadrigemina ; 
-Ap, aqueduct of Sylvius from third to fourth ventricles; Vm, middle or third 
-ventricle; cm, middle commissure; Om, medullary fibers from occipital 
lobes to pulvinar and knees of internal capsule; M, ms, other medullary 
libers; R, occipital cortex. 



I Hi. 13. 



FIG. 16» 







FIG. 17. 



dm illustration, Fig. 16, Is n neuroglia cell showing dendritic branching 
ami inu«kitiehn of its ptoci'sscs. From the white brain matter of sheep. 
Mils form I* common in growing brains, it is to be regarded as a neuroglia 
cull that has not yet reached full development. Fig. 15 is a large neuroglia 
i ell attached to vessel wall. From the white matter- of brain of sheep. 
Most of the processes show no branching. This is the typical form of the 
fully developed neuroglia cell. (After Ford Robertson.) 

Fig. 17 shows a pyramidal cell from the cerebral cortex with the nucleus 
and nucleolus, while immediately to the left (Fig. 18) is shown neuroglia 
cells of the (iolgi type, after Kolliker. 



NEURONES, EPITHELIAL CELLS AND NEUROGLIA 
FIG. 19. 





FIG. 20. 

Description over. 



The upper illustration (Fig. 19) shows ganglion cells or neurones, A and 
B, after Panvier: C are neuroglia cells. Spider or Dieter's cells; Distn 
axis cylinder process or neuraxone; P are protoplasmic processes. All 
from the spinal cord. 

The lower illustration (Fig. 20) shows epithelium and neuroglia sur- 
rounding the central canal, section through the spinal cord of a human em- 
bryo of twenty-three centimeters length. (After Lenhossek). 

Neuroglia is a peculiar tissue. It belongs exclusively to the central 
nervous system and the optic nerves. It is a patching, making patchwork 
connections for damaged nerve connections, as well as being a neurone-sop- 
porting network tissue or scaffolding. It not only does the work of glue, as 
its Greek name indicates, between the neurones, scaffolding and holding them 
in their proper relations, as I have already said, but it acts as a sort of 
plug for stopping neural holes. The neuroglia is often simply called gilt. 

1 ' Wherever in the central nervous system nerve substance degenerates 
from disease, the glia (neuroglia) appropriates the empty space. The re- 
placement with glia has a limit only where its elements are destroyed along 
with the nerve substance and where its power of growth is not sufficient to 
fill up the large deficit 

"The central canal and the ventricles send long processes Into the 
nerve substance. In man these reach the external surface only in a few 
places. These fibers as in the figure above belong naturally to the sup- 
porting tissues. 

"The neuroglia net differs somewhat in different parts of the central 
nervous system and forms here and there dense accumulations In parts 
quite devoid of nerve substance. Thus, a thick layer of nearly pure con- 
nective tissue covers the whole surface of the brain and cord and extends a 
short distance along the nerve roots in the form of a plug. In the same 
way there is found on the inner surface of the central nervous system just 
under the epithelium an especially rich development of neuroglia. The net 
work in the gray substance is in some parts denser, in others less dense, 
than in the white substance. The large nerve cells are frequently so en- 
circled that they appear to lie in a tine-meshed basket."— Edingtr. 



GROUP OF NEURONES MAKING NERVE CENTERS. 
FIG. 21. 




^ v ~* +*'■<* "Jul 






iVrnmklnl cctln from !h* fpjnta-piLi-it't&l region of * 
cat's fotte *t term* Ci obL , no cye-pieea, ) 



HI<J 22, 

The Association Fibers 




JIU\V*X x oc%Wv<- ^*K^»tq\, 

030.7: $*<*«.\ ^«w^\«*/. £/r/r c«r«*«a.i »•«*«*. 



CHAPTER IV. 

THE neurone continued; its efferent prolongation or prolif- 
erations. THE AXONE, NEURAXONE, NEURITE OR AXIS-CYLINDER 
PROCESS; THE NERVE CELL AND ITS BELONGINGS. HISTO- 
LOGICAL COMPOSITION OF NERVE CENTERS. THE 
NEURONE AND ITS DENDRITES OR AFFERENT 
CELL PROCESSES. THE NEUROGLIA.* 

In the preceding lectures we have endeavored to fix 
in your minds the idea of the neurone as a nerve center 
unit of impression, elaboration and expression. A unit 
of action, a unit of independent, yet of communicative ac- 
tion, impressed i. e., receiving impressions from other 
neurones, acting upon those impressions and sending out 
other impressions to neighboring neurones or receiving im- 
pressions from the blood or from the periphery or from 
environment and of making impressions on circulation and 
viscera and of extracting nutrition from the blood. 

The neurones are composed of nuclear centers and nerve 
fibers. They are the nerve cells and their belongings con- 
sidered as independent units of impression and action. They 
are noarished by vessels and have vessels coming from them 
as you may see in some of Golgi's demonstrations and have a 
microscopic lymph about them which you will better under- 
stand as you advance in the study of neuro- histology. This 
lymph, which is essentially a cerebro- spinal fluid, bathes 

•See preceding and following Illustrations. 

[43] 



44 

llit'iit a* tin* biam iv bathed ^ sut\irAchnoid and ventricular 
lluld iiiul ax the s*hmI voiv! swt?r> % tike a pickle suspended 
fh'in tlu* luvk ol ** mu v.* svr*No*spinal fluid or like myriads 
el ||v«|i Iimuc m .1 \aw vA-.tt v nVvi with water. The nerve 
it \\\\\ \s*\\* a\\\\ then n*Io«^:^n make up the neurones. They 
!lv»' and mow a»ivl l».uv i the ■■; owac. s:» to speak, in a san- 
MiiIim> a*|neon« medunn.tfvu !:re pabulum is sanguino- serous 
himI (In l»U»\sl !■* Uv una! a \! ot.rtAt? life thereof, as they 
hi hi»M nnv tv the Inv o» death or the Mood through physical 
<i |< •> ■• hi* al \w\w * w*i\W\ vhxk a:k! ttruierices, exaltation or 
I* |<M ..-linn el nei\e wmuoin. on the metabolisms of the body- 
I In iu nu'nr« haw vmixv'n or v.ppy and waste, nutrient 

» iv< I • » I •, vU , a»Kl vi;ss^i-5; tissues to keep them in 

/'Ml ' and nound |v\ttva % v\iox\ etc. These tissues are 

'II' I m> iiiuiilia 01 hiete»\ ,\ i :\, connective tissue, etc. The 
m-m"iJi» I- what u* neav > *nvc^ -a neurone glue (*wpw t a 
h- i • and iV"*, uhu ^ Hut ,!v'\.iv sonnecttve tissue frame- 
W'»»|i wlii»h upnou-Mhs iK'iwviM'io: And blood vessels of 
ih« I'Miii and |uu.*l ,oul, oix . a:\? holds them and the 
Htinnih . m llhii po^-i r'asON. I no neuroglia has been 
ilium . I hum lite. -.uw^ed i-m-, >ot lot me tell you now 

.; lli.il \iiii ma\ not Hunk ii!.u \o.: k vw it all, from what I 
• ■ay lit llu-'.i laui Linio, [\w\ ofv: and more important 
inn. iiun:» ha\o I>mu lau-i\ .i\::\J to tic neuroglia, that tend 
Id |ii\i- 1 1 u in a hiidwa vi:ij.i\ » t>. x vv retro-spinal axis 
Hi, in nun- ^aiioldui^ or \onx x ; n -»/ -vr\e cells, but as I 
hhall ma examine Ni»u on Uj.n n..>w; ! w;'.: not ask you to 
i an y in \ uut aheady iall\ eve.de nod .erebr a! -cortex neu- 
iiiiicb, nuue iumolo^\ ihan \va w: . oo a^kvd to exhibit in 
tin* gu-i-n iiuiiii at \\n\\ \\i\a\ e\a: ,x :->o,tvn. Your psychic 
neiiione^ will he tiu-d -ononis at t!u- end of the session 
aiul I will not ow-itmideu thesn w.t 1 * ai: \\; teachers know 
oi think we know on the %abvct, '.c^t you might have, at 



45 

the end of the curriculum, too much neurasthenia involving 
your cerebral neurones, (cerebrasthenia,) to unburden your- 
selves with credit, for a tired psychic neurone does not do 
itself justice under mental strain. It needs rest, recreation, 
retraction, sleep. After prolonged exercise the tired 
neurone is neuratrophic and needs a chance for re- 
pair and recuperation. Prod it under these circumstances 
and it may act unstably and not to the best interest of the 
brain that owns it. Take good and tender care of your psychic 
neurones during the course of work before you. You are 
in the arena of supremest effort, and the neurones of every 
one of the five or six layers of your gray matter will require 
all the aid of sleep and exercise and rest and ample food and 
abstention from vicious habits, long study hours and worry 
that rob you of rest and repair, that you can give them. 

Do not imagine from the block demonstration I have 
given you of the action of one neurone upon another that 
each neurone bodily falls upon another. The blocks in a 
row were only produced to show how the impulse of one might 
be communicated to another, for the neurones have prolonga- 
tions for communicating purposes. These proliferations touch 
other neurones but do not interlace with them, as was until 
lately taught. They come in contact, but do not intertwine 
with their neighbors, they touch but do not mix. They com- 
municate by means of neuraxones and dendrites as you gen- 
tlemen do with each other, with your arms and hands. The 
long communicating arm of the neurone is called the neu- 
raxone or neurite, formerly axis cylinder. The dendrites are 
the short receiving arms of the neurone. One neurite is an 
efferent or outgoing process, carrying out impressions (from 
the Latin, ferre, to carry, and ex, out of,) the other is an 
afferent prolongation carrying impressions to the neurone 
(from ferre meaning to carry, and ad, to). 



46 

The axis cylinder, or axis cylinder process, is the most 
familiar and longest used term and writers still speak of the 
cell and axis cylinder process, the two together making, with 
the dendrites, the neurone and glia cells between. The 
ganglion cell with its nucleus and nucleolus, neuraxon and 
dendrite, make the neurone. Neurones are a physiological 
developmental unit, standing isolated but yet grouped to- 
gether, as 1 have said, touching their neighbor neurones 
physiologically or pathologically in health or disease, and 
passing on to each other healthy or unhealthy impressions. 
Take care of your neurones and the neurones of your patients 
as you would take care of your characters and purses 
and the good name of this college. Take good care of the 
tone of your neurones and they will take good care of you. 

The independent individuality of the neurone, notwith- 
standing its dependence upon others in the same nerve 
center grouping, is proved by the well -observed facts of both 
experimental and morbid pathology, that the effect of its 
disease or injury are so often found circumscribed to the 
diseased or injured body of the neurone and its processes. 
If the axis cylinder of a peripheral nerve or the neuraxon of 
a central neurone (the same thing), be studied under the 
influence of mechanically induced disease, its diseased condi- 
tion will reflect the disease of the central source in the gan- 
glion cell or neurone. The life or health of all parts of the 
neurone depends on the health or integrity of its body, mainly 
the nucleus. If this is diseased the remainder degenerates 
or dies. Neither the neuraxones nor dendrites can live 
independently of the neurone body whence they arise, any 
more than our limbs might live without an attached body. 
The reverse also takes place but not so markedly or so 
rapidly. Diseased processes in neuraxones or dendrites will 
sooner or later and more or less involve the body of the 



47 

neurone whence they arise just as a disease of the hand 
may spread to the body. 

The following experiment with contiguous, rocking, not 
falling blocks made secure so that they may move back and 
forth and expand and contract without falling down, and 
supplied with projections to represent the neurites and den- 
drites, may serve to make plainer the method of movement 
of the neurones in your anatomies. 

Now let a few of the students come down into the 
amphitheatre and stand near enough to touch each other 
with elbows akimbo on one side and arms outstretched on 
the other, the long outstretched arm and hand representing 
the long axis cylinder or neurite or neuraxone, the short pro- 
jecting elbow akimbo representing the dendrite and you 
have the neurone theory of Ramon y Cajal illustrated, and 
vitalized so that I hope you may not forget it, but do not 
keep up the illustration any longer than may be necessary 
to impress it on your respective psychic neurones, or you 
may make a bad neuritic impression through my psycho- 
neural dendrites on my psychic neurones. 

fig. 23. 




II '4 »|4iu] a *M»»t4<w|attli«t*aM*il4iffi»*thrMMt4i)rw«. * 
• ilk bvT •taUiwatr^ Htm<w. La**: _. 




4.!|)«( •)-"»> £M>glMa *T MMUMi Ho«. lAW'-i fc* tJJ» . **H»«W 



FIG. 24. 









WtwicM « #V4 r 




I, Scheme of the brain. — C, C, curies cerebri ; C.j, corpus striatum, NV, ■ 

1.0, optic thalamus; t», corpora quadngernioa ; P, (teduoculus cerebri; H,. lej, 
•ad/, crusts; I, I, coruna radtata of the coqtut striatum; 2, a, of the leatkalar madam; 
3, 3, of Ibe optic thalamus; 4, 4, of the corpora quadrigemtna ; 5, pyramidal fibre* from 
the cortex cerebri ( Hetkuf) ; 6, 6. fibres from the corpora quadrigemina to the tagmm*am ; 
m, further coane of tbcae fibre*; 8, 8, fibres from the corpas at rial am aad ltmaralm madam 
to the crusts of the pedunculus cerebri ; M, further course of theae ; S, S, causaaa af flat 
sensory fibres; K, transverse section of the spinal cord ; .--. W, anterior, aad k. W,amaafffiar 
roots; it, a, association system of fibre* ; «, <-, commissural fibres. II, Tramsmat aacmaaj 
through the posterior pair of the corpora quadrtgemina and the p admsta li cerebri «f mem 
— /. crusts of the peduncle ; j, substantia nigra ; v, corpora quadi igt mma. vim ia 
of the aqueduct. Ill, The same of the dog; IV, of an ape; V, of the apaamvajg, 

toovSou? auk Stf rVmgt ^h^s'idlo*^ 



FIG* 25. 




WBrebtirg Gutgj jiri-panitfou. Cell 
from til-- csrfiotJ yrmpntbetic iu a aUf. 
t«) Tl»t i neuron ; [f\ tht itcitruxotij frtfj 
fiptirodriidrit^. (VVVc^AAOTrvy 



I 



CHAPTER V. 

OH MINI! lOkMS AND I UNCTIONS OF NEURONES. POLAR AND 
AI'OI.AK, HI-POLAR AND MULTI-POLAR NEURONES. 

hM UOf.l AM) Nl l/VI Oil.; SYNONYMOUS IN A BROAD SENSE. DISEASE 
CHANGES IN THIi NEURONES. 

I In- neuione is a microscopic mass of finely granular 
|ii<>to|il.i'>iti surrounding a nucleus, this nucleus including a 
nu< holus, sends out prolongations or proliferations which 
are ' .illi-el p«»l««s. Some neurones have none of these poles 
.•ii«l are 1 1**1 it t* called apolar neurones; i. e. t without 
poles. Others are numerically designated as uni- polar or 
mono- polar, one poled; hi -polar, two poled; and if possess- 
ing thicr poles or more, multi-polar or many poled neurones. 
1 he neiiraxoiie, neurite or axis cylinder process, all meaning 
the same thing, proceeds outward as one of these poles. It 
is an eltereiit prolongation designated to carry out the nerve 
eneigy elahorated and stored in the neurones and commun- 
i< ate the neurone's energy to a neighboring neurone or 
elsewhere. It a^ts upon impressions received from other 
neurones, changes them, as in retlex neurone centers, into 
motor impulses, modifies impulses and impressions and 
elaborates and originates new impressions to be sent out 
along the neuraxone. This is something of a repetition but 
it is important for you to remember it. 

The Greek term kvtos, and the Latin cella, both mean 

[48] 



49 

a chamber, and in these little neural chambers of the brain 
for instance, wondrous movements go on and miglfty though 
silent and inobtrusive forces reside. In the little neur.one 
chambers of the gray cortex dwell psychical tenements 
which manifest to us the mind and soul of man. You must 
be mindful of them — these psychic central neurones. The 
manner in which you impress them in practice and the 
effect of disease on them will help or harm your patient 
and make or mar your professional careers. 

The terms cell and neurone are yet often used by 
writers in a synonymous sense, they meaning to include in 
the term cell as thus substitutionally employed for neurones, 
all of the already described constituents of the cell, which 
make the nerve unit or neurone. Thus Barker* in discussing 
the cells of the human cortex, meaning thereby the neurones, 
for he is speaking of the neurone as a unit, quotes from 
the indefatigable and brilliant Franz Nissl, an authority you 
will bye and bye become more familiar with and much 
more interested in than you are now, for he is the author 
of Nissl's stain and has made many great and valuable 
contributions to our knowledge of the anatomy and pathology 
of the neurones, who in a recent paper ("Nervencellen 
unJ grau Si^stai^," Muenchener Medinische Wochenschrift \ 
189S, a great German medical j nirnal which will much in- 
terest you who read German) distinguishes seven forms 
of alteration in the cells of the human cortex, viz., acute 
and chronic cell disease, combined disease forms, severe cell 
disease, vanishing of cells, simple tumefaction and granular 
breaking up of cells. Barker goes on to tell us, and you 
mjjst consult Barker's great bi>ok when you have time to 
pursue the subject at your leisure, that Nissl lays much 
emphasis on the first of these forms, the so-called acute 

♦Barker. Nervous System, p. 12**1. 



so 

cell disease. According to him it runs the same course in- 
every instance, having always the same termination, anc3 
when it has once appeared it involves all the cells o»- ^ 
the cortex without exception. The changes are sc 
characteristic that after once seeing them, one can make 
positive diagnosis without difficulty. The disease does nor- <^& 
affect a part of the cell only, but involves the whole=» e 
neurone, the stainable as well as the unstainable substance. ^=s 
the nucleus as well as the cell body, the axone as well azz -«s 
the dendrites, all parts being involved apparently in the sam^ *>* 
degree. In this form of neurone change the unstainable *l e 
substances are so altered that they become stainable, a far r^ct 
that makes Nissl think that his ''unstainable substance* ^ ^" 
consists not only of a fibrillary constituent, but in addition m^w n, 
of one or several other substances. 

Nissl finds this acute cell disease not only in acut> ~^ -*e 
paralyses but in a great variety of psychoses, and also ir * ,n 
patients who have not been the subjects of mental diseas^^ se 
in the ordinary sense, but who, succumbing to various dis-^=^ s- 
orders, have before death been partly delirious, parti: & 'y 
somnolent. The involving of all the cells in the cortex i« /5 
an exceedingly interesting feature, and one met with rareh **y 
in any other form of disease. All the psychic cortex neuJ^*" 
rones are more or less involved in delirium and the delirioi^" 5 
forms of insanity. 

An instructive paper dealing with the alteration dis - 
coverable by Nissl's method in the human cortex and als<? 
quoted by Barker is that of August Hoch (Nerve Cell Changes 
in Somatic Diseases) of the McLean Hospital, of Waverly, 
Mass. Working in NissPs laboratory at Heidelberg. Hocli 
had been impressed with the frequency with which changes 
had been found in the cortical cells of individuals dead of 
diseases of different kinds. Recognizing the importance of 



51 

a thorough knowledge of the possible changes in the cells 
in somatic disease for the interpretations of the pathological 
alterations met with in the brains of the insane, Hoch 
directed his special attention toward these. In the paper 
mentioned he deals with a particular cell alteration which 
he designates as "cell shrinkage." He has studied this 
change in human beings, in whom it occurs in the most 
diverse diseases, and also in experimental animals. 

This alteration of the cells, as he describes it, is found 
chiefly in the medium and smaller sized pyramids, as well 
as in the cells of the fifth layer. The contour of the 
neurone is distorted and shrunken, and there may be much 
retraction of the borders of the cell body between the pro- 
cesses, so that a part of the cell body may, at first sight, 
look like a part of a cell process. A well marked honey- 
comb is visible in the cell body, and is sometimes indicated 
in the processes. The nucleus is darkly stained, diminished 
in size, and is often distorted. In Nissl preparations it looks 
homogeneous; the nucleus is often oval in shape, and may 
be paler than normal, but never shows a purplish hue. 
Instead of the honeycomb appearance the protoplasm may 
be "crumbly looking." But I cannot go on discussing in 
minutae this interesting subject. You will not be expected 
to be experts in cytology like the great masters in order to 
acquire your degree, but to acquire accurate general in- 
formation on the subject and to know where to search for 
it and find the knowledge you will thirst for and need as 
you advance in the study and practice of the great profes- 
sion you have chosen. 

It is a fact that changes in the neurones and neurone 
groups or nerve centers precede, accompany, or correspond, 
to all changes in function of organs innervated from or 
through them or through their influence, whether these 



52 

changes may always be demonstrated or not. All alteration 
of function in cell action is accompanied with correlative or 
corresponding alteration in structure, either in change of form 
or relative position of cell molecules — changes of shape or 
texture. This is a law that pervades all nature. You know 
in nature the trembling of a leaf, the waving of a bough and 
the movement of the wind and the ripple in the brook where 
you bathed and fished, differ as the movement of the different 
powers of the lever, of the wheel axel or the pulley. Differ- 
ences in shape, structure and adjustment make the differences 
in motion in mechanics and physics. It does the same in 
physiology and pathology. Variations in quality or quantity ot 
plasma, in blood supply, in form and texture of organs, viscera, 
nerves or entire nerve cells or neurones, cause variations 
in action, in disease, contrasted with healthy physiological 
and anatomical states. Physiologic or normal or natural 
function in organ or neurone is health and pathology or 
diseased function is altered physiological structure and ac- 
tion — /. <*., normal function changed by morbific or disease 
engendering cause. Physiology is anatomy in action, disease 
is pathology in action, whether in aggregate organ, the 
components of its cells or the entire cell, /. e., the nucleus, 
nucleolus, axis cylinder, neuraxone and their ramifications, 
all of which contribute to make the neurone. A neurone 
diseased, acts abnormally and in order to act abnormally it 
must be anatomically diseased in shape or size or structure 
or in the plasmic structure or neuroglia that holds the neu- 
rone in place. The old axiom of creation, ex nihil facere, is 
a fallacy; something cannot be made from nothing. 

As this is true, so also is it true that no absolutely 
functional disease can exist. We speak of functional nerv- 
ous diseases as those diseases which as yet have no 
definitely discovered underlying pathologic cause, but we 



53 

do not mean thereby that only function is disordered without 
actual causative structural change. In functional diseases of 
the nervous system so-called, causative conditions undoubt- 
edly exist in the dominating neurones beyond the ken of 
science in all nervous disease or they are in the nourishing 
pabulum, the blood or blood serum supplied them, as in 
anaemic neurasthenia, in which we know the impoverished 
state of the blood but not the precise condition always of 
the neuratrophic cell or neurone that causes the character- 
istic debility and peculiar symptomatic fears. When the great 
Virchow promulgated his cellular pathology he used the 
term cell, when referring to the central nervous system, in 
much the same sense as we now employ the term neurone. 
Though the neurone theory, the individuality and independ- 
ence of the neurone as now understood, was not then so pre- 
cisely known in neuropathology and neurophysiology, yet he 
founded the cellular pathology. Under your microscopes in 
the biological laboratory you will discern many varieties of 
appearance among glia cells and neurones and also in your 
text- books you will find them described. The study is fascina- 
ting but I cannot go over it all, nor can you during the term 
and do your other work well. Only bird's-eye views are 
here permitted as to the flying visitor, but take in all you can 
at a glance. 

These neurone variations have to do with the differences 
of physiological functions, as the pyramidal shaped neurones 
or cells of the grey cortex of the brain and the motor neurones 
of the anterior cornua or horns of the spinal cord, and of the 
ganglionic centers of the sympathetic system. Not only the 
external morphology but the internal morphology of the 
neurones constitute a vast field of research as up to 
the present time discovered and the field will grow wider 
for your entertainment and your instruction as you go on 



or proceed along the pathway of medical cytology. The 
internal and external morphology and the grouping and 
chaining together of the neurones constiute the burden of 
I. owelty n Barker's great labor as revealed in his recent 
meat book of more than eleven hundred pages of plate and 
copy, on the nervous system in its cytological aspects. 

Neurone changes have been shown of the effects of 
mcieased body heat by Goldschneider and Flotaw, and from 
poisoning by Malol nltrit and tetanus toxine, after section 
ot the nerve root in rabbits by Erlanger. Spinal cord 
neurone changes have been shown by Marinesco and others 
tiom cutting ott blood supply, and of the end of the spinal 
cord in cerebio- spinal meningitis by Barker, who produces 
all these I have mentioned and many others in his splendid 
book, and Ntssl, Yangehuchten, Berkley, Robertson, Morrison 
and otheis have shown the changes of neurones under 
arsenic, alcohol, etc. 

Intoxications and infections, animal and mineral, both 
trom within and without the human structure alter the 
structuie and function of the neurones and consequently of 
all organs or parts of organs dependent upon them for 
speech expression. Alcohol may so change the neurones of 
the speech center of Broca as to set the tongue to wagging 
or so as to paralyze it, or of the psychic neurones of the 
several layers ot the grey cortex of the brain so as to increase 
mental action to boistrous insanity or depress it to alcoholic 
coma or so effect the psychic or psycho-motor neurones as 
to cause alcoholic epilepsy, (that is a fit of coma and con- 
vulsions induced by the alcoholic poisoning of the psychic 
and psychomotor areas of the brain with irritation and 
paralysis of the vaso-motor centers). 

A proper understanding of the neurones and the parts 
they play in healthy and diseased states is a large part of 



the study of neurology and psychology and a knowledge of 
the effect of medicinal and other influences upon them is a 
large part of the neuriatry or healing of nervous diseases 
and psychiatry or the treatment of mental diseases. 

Regis, who writes so concisely and so well in his manual 
on mental medicine which I have before referred to, has 
contributed a number of recent monographs and so have many 
other authors on auto- intoxication and delirium — the psy- 
choses of auto-intoxication — and the post eclamptic psychoses. 
Here the psychic psycho- motor neurones are potently and 
morbidly touched as we see them changed in action by the 
intangible and visually undiscemible virus of a fever, save 
when we bring microscopic lenses of great magnifying power 
to our aid postmortem. We may see evidences of the 
neurones being lightly touched as in the delirium of 
bilious remittent fever so-called, when the bacilli of 
Laveran invade the brain cells lightly and resistance is great 
or they overwhelm ^resistance, when the cerebral congestion 
of a "congestive chill" sets in, or in the still graver states of 
septic infection or of typhus and typhoid and the grave deli- 
rium that ends life. In these fatal states when the life of all 
the blood is touched corruptibly and "the poor brain doth by 
the idle comments that it makes foretell the ending of 
mortality," the death dealing microbes and disorganized 
blood have got in their fatally destructive work, not only 
upon the vitality of the neurones of mental movement 
in the domain of psychic life and dethroned mentality, but 
in the vital centers of organic life and cut short vital 
metabolisms or essential changes of existence and destroyed 
vital visceral functions. When the neurones are embarrassed 
by toxic germ or auto-toxine, function fails. When they 
are poisoned till they cannot functionate, their actions are 
palsied and the functions and life they govern cease. 



FIG. 24. 






** 




I, Scheme of the brain.— C, C, cortex cerebri ; C.j. corpus striatum, N./, ni 

T.<», optic thalamus ; t; corpora quadrigemina ; P, pedunculus cerebri ; H i# 

and /, crusta; I, I, corona radiata of the corpus striatum; 2, 2, of the ' * 

3, 3, of the optic thalamus ; 4, 4, of the corpora quadrigemina ; 5, pyi 

the cortex cerebri ( Hechti£) ; b, 6. fibres from the corpora quadrigemina to the 

/»/, further course of these hbrcs; 8, 8, fibres from the corpus striatum and lead 

to the crusta of the pedunculus cerebri; M, further course of these; S, S, 

sensory fibres; R, transverse section of the spinal cord ; i\ \V, anterior, and A. 

root*; a, a, association system of fibres; <-, t, commissural fibres. II, TraM 

through the posterior pair of the corpora quadrigemina and the peduncuK CCreM «f 

—/.crusta of the peduncle; t. substantia nigra; v, corpora quadrigetnina, wfek « 1 

of the aqueduct. Ill, The same of the dog ; IV, of an ape ; V, of the gwiaca-pig. 





-Wtttsbm Ctil 

froirj (].» 



i 




FIG. 29. 




Fig. 28 represents the cell of anterior horn of the spinal cord of a 
normal rabbit, while Fig. 29 is the cell of the anterior horn of the spinal 
cord of a rabbit with experimental elevation of temperature. Both are after 
Ford Robertson. 



FIG. 32. 




—From the cornu Ammonis of the rabbit A, Composite figure from 
preparations by S. R. y Cajal. •*. b, e, Association-cells whose long neuraxoos 
split up into moss-like twigs, which invade the layer of pyramidal cells (4). 
At the left is a completely-sketched pyramidal cell. Through its descending 
neuraxon it is in relation with the "brain-pith" and through its ascending den- 
drites it is in relation with other systems snd cells not figured. Through the asso- 
ciation-cells many pyramidal cells are brought into combination. ^ 

HOW CORTEX NEURONES COMMUNICATE AND PROJECT. 
FKi. .tf. 




Schema showing tho probable muwr of impulse «n<l the inVrneu- 
ruuHl connection* in tin- ii.rtfi n-n-hri. (Aftrr S. Ifem/m y (Vial, Lr» 
nouvenr* idee*. ,t,-.; t Aft.ul.-iy. Paris, 1MM. ,, 6A. Kit. Ill \ A. *mal?|iynini- 
HS*u Ui ' T^ P- Y iL inn,, » tr . U : f • "• l"»lymorpli..iiH o« IN ; f.\ ti rniinal 
wX iff.* 01 ? r, fc ct, ° 1 L ? bn 7 * «»««*«mI» ^.m the Mih*t»ntia slha; f,\ axuns 
binircatinft in th«; Mibatantia alhu. 




Scheme of the fibrce propria' connected with the commissural system of 
the brain convolutions. 



BERKLEY'S DIAGRAM OF THE PROJECTION FIBER SYSTEM 
OF THE BRAIN. 

FIG. 36. 




Showing the origin and course of the pyramidal and callosal libers. 
P, pyramidal tract; C, callosal commissure; A, cell sending an axone 
directly to the collateral hemisphere; B, H, cells having branched ax ones; 
the main fibers descend into the pyramidal ways, and the collaterals cross 
to the opposite half of the brain through the corpus callosum; I, I, cells 
sending fibers directly into the pyramidal tracts without branching. 



FIG. 38. 




FIG. 37. 



FIG. 39. 



FIG. 40. 




FIG. 41. 



MKYNERT'S SCHEME < >E THE COMMISSI RAL FIBER SYSTEM. 



FK.. 42. 




lor further description ser Chapter V|. 



CHAPTER VI. 

• 

THE NEURONES GROUPED INTO LAYERS OR STRATA OF THE BRAIN 

CORTEX; FURTHER CONSIDERATION OF THE NEURONES AND OF 

THE ASSOCIATION FIBER SYSTEM OF THE BRAIN AND OF THE 

PROJECTION SYSTEM OF THE BRAIN AND SPINAL CORD. 

FUNCTIONS OF NEUROGLIA AND MESOGLIA. 



The neurones of the cortex are often distributed over 
six or more layers, laminations or strata. This cut of Mey- 
nert (Fig. 34) shows the five motor strata with their neu- 
rones as usually described. The sensory areas have more. 

The first zone or stratum is made up of polymorphous 
neurones of what are commonly called cells of the Golgi type. 

The second layer is composed of small pyramidal neu- 
rones with intermediate connecting glia or Dieter's cells. 

The third layer is composed of medium sized and larger 
pyramidal neurones. 

The fourth of compacted small pyramidal cells. 

The fifth of medium, large, and giant pyramidal neu- 
rones, and the sixth is made up of medium-sized polymor- 
phous neurones, mingled with the substratum layer of white 
substance described only as white substance by Meynert 
as you may see by reference to the illustration, from that 
distinguished neuro-anatomist, to be seen in Fig. 34 of 
this volume. Meynert's illustration which 1 show you gives 
the neurones in th* motor area of the anterior lobes; the 
five strata layers. 

[57] 



58 

The six or more stratifications or layers of the brain do 
not belong to the motor area but to the "annectant gyri M 
which connect the occipital and parietal lobes. These six 
or more layers belong to what has been called the sensory 
type of neurone layers of the brain. 

The first layer, beginning in the cortex, just beneath the 
meninges, contains the so-called tangential fibers. Where a 
sixth layer is recognized it is constituted of medullary sub- 
stance containing a few spindle-shaped neurones. The neu- 
rones of the first layer are irregularly angular with angular 
nuclei, those of the second are small pyramidal. The third 
are larger pyramids in shape. 

There are many varieties of neuroglia besides those of 
the Golgi type which 1 have shown and Ford Robertson's 
mesoglia, like unto them. 

Fig. $7 shows an ependymal cell from the pituitary body 
approximating the embryonic type; Fig. 38, ependymal cells 
of fir-tree form from the margin of the third ventricle adja- 
cent to the infundibulum; Fig. 39, long-rayed neuroglia cell 
from the fourth layer of the cortex, a transition form between 
the ordinary long- rayed and mossy form; Fig. 40, neuroglia 
cells of horse-tail form from the peridyme of the brain. The 
free surface is covered with a felt-work of the longitudinal 
fibres; Fig. 41, a mossy cell with knobbed branches from 
the gray matter of the cortex. All are from Berkley. 

Figs. 37, 38, 39, are from the adult dog, the others are 
from man. Berkley has transcribed into his masterly work 
on mental diseases sixteen varieties, some of which 1 show 
you as tending to confirm the conviction he expresses that in 
addition to Binswhanger's view of their gliacyte or cell con- 
necting function already referred to, they serve the double 
function of support and separation of cells, neuraxones and 
dendrites besides being "factors in the lymph circulation" 



59 

which has been hinted at in our reference to the irrigation 
system of the brain, the perivascular spaces, etc. 
"In human movements though labored on with pain 

A thousand movements scarce one purpose gain, 

In God's, one single can its end produce 

And yet serve to second some other use." 

And so it is, probably, with the relationship of the 
neuroglia to the neurone. 

And so doubtless you will conclude from an examina- 
tion of these varied illustrations, a few of which I reproduce 
for your consideration and perhaps some of you may make 
the necessary investigations to settle the question here pro- 
pounded, do the neuroglia nourish as well as mechanically 
support the neurones? Fame lies in the paths that may 
lead you to a correct, unerring answer to this important 
question. Remember as you study this subject what 1 have 
told you of invariable variations of structure corresponding 
to deviations in function and note how differently in appear- 
ance and construction is the ependymal neuroglia cell from the 
pituitary with that fir-tree form of the third ventricle neu- 
roglia and that of the fourth layer of the cortex and compare 
these with the mossy glia cell No. 10 of the second layer for 
the neurones and that, besides mechanical support which is 
demonstrable, the neuroglia may give the neurones physio- 
logical support in the way of lymph nutrition, this latter, 
however, being yet only conjectural and 1 will pass you on 
this answer or if you but say the neuroglia act the part of 
a physiological scaffolding glue to the neurones. Apropos 
to your future investigations, read Bevan Lewis' discussion 
of the lymphatic system of the brain and especially before 
and after the paragraphs I here quote.* 



♦Beyond the system of perivascular channels, adventitial lymph space, and perivascu- 
lar sac. we have a lymph -connective system which plays an important role in the pathology 
of the brain. This system is constituted by the larger connective element. These elements, 
more closely examined, are found to have a definite and constant relationship to the cortical 
blood vessels; and are always discovered In large numbers in their Immediate neighborhood . 
external to the perivascular channels.— Bevan Lewis, page 83. 



60 

Are the neuroglia connected with the nutrient lymph 
system of the hrain? 1 think they are. Golgi, Clouston, 
Robertson, Berkley and others think so, and Ramon y Cajal 
says: "They expand and contract the capillaries to which 
they are attached." Study up this subject. 

W. Bevan Lewis, t considering that recent research into 
the general morphology and intimate histological structure 
of the nerve cell has so far enlarged the boundaries of our 
knowledge that it becomes essential to start with a definite 
terminology which includes no ambiguous terms for the 
complicated apparatus presented as the modern conception 
of a nerve cell, would thus describe the neurone and its 
several components. 

The body of the cell including all its contents, he calls 
the cell or neurocyte; the protoplasmic body of the cell, in 
contra-distinction to the nucleus, he proposes to term the 
neurosome or cytoplasm. If the cell is provided with pro- 
toplasmic processes he would speak of the main trunk as 
the dendrone, and the finer arborizations as the dendrites. If 
one of these occupy a polar position whilst the others rise 
from the base or sides, as in the pyramidal cells of the 
cortex, he would designate the former as apical or primary 
dendrons, and the others as lateral, basal or secondary 
dendrons. The dendrone, remember, is not an essential part 
of the cell, since many nerve cells have no dendrone. The 
axis, cylinder, he thinks, may be much more conveniently 
termed the axone, which may be naked (non-medullated) or 
medullated, and such branches as arise along its course as 
collaterals. The distal termination of an axone or its col- 
laterals in a plexus he designates as terminal arborization 
and for the whole system thus embraced, i. e. t the neuro- 
cyte with its axone (collaterals, terminal arborizations, and 

tText-book Mental Diseases, 2d edition, page 60. 



Ol 

If present, the dendritic expansions), we use preferably the 

~*erm neurone in the original sense adopted by Waldeyer.* 

I show you these great things from the great masters 

~*o set you to thinking; not that I expect to make you at 

once great cytologists like these masters are; nor that 1 

«xpect you to remember minutely all 1 tell you. 

Tell me at the final examination that the neuroglia, 
though varied in form, are connecting tissue supports to 
l*eep the neurones in place and maybe to help feed them, 
and your answer will be satisfactory. It will even be sat- 
isfactory if you only know and say the neuroglia are the 
framework of the neurones, for this is all we now seem 
absolutely to know. But you may conjecture other func- 
tions for these intermediate structures between, some of 
"fchem looking like spiders, others like whips or horses' tails, 
others like the branches and stems of trees, and to prove 
view functions for the neuroglia if you can and 1 expect to 
fciear from you affirmatively in the on-coming days of your 
fcigher neurological climbing. Men climb in science as boys 
<:limb trees, from trunk to limb and from limb to smaller 
fcranch till they reach the possible top. 

From what 1 have thus far said it must have already 
appeared to you, that to know the neurones well is to 
l<now neurology. You have seen that a neurone is a min- 
iature nervous system. It has in its nuclei its central system 
and in its neuraxone and dendrites its peripheral connective 
system, afferent and efferent, and neuroglial relations, its 
association and projection fibers, as 1 have said. Aggregate 
these single neurones and neuroglia and you make the brain, 
made up of the prosencephalon or fore- brain, the thalamen- 
cephalon or inter-brain, the mid-brain or mesencephalon 
and the hind and after-brains embracing the pons, cerebel- 

+Dtuttckt Mtdicinaliicht Wochenuhrift, 1891. 



62 

lum and medulla. The grouping and "chaining together of 
the neurones" or their normal integrity, anatomically held 
together by means of their neurone and neurite prolongations 
and neuroglia, make the projection paths and association 
paths and make possible the physiology of the entire nervous 
system, the entire cerebro- spinal axis and peripheral systems. 

The severing of a single neurone link in this neurotic 
chain or the damaging of the neuroglia which hold the links 
of the nervous chain in normal place, makes neuropathology. 
It may be very slight, so slight that we cannot detect the 
anatomical change, as in the so-called neuroses, as formerly 
more generally understood, or functional nervous diseases. 
They were originally so called as they are now because 
the anatomical change into pathological change causing them 
is not yet definitely detectable. But neuroses are nervous 
diseases with pathological bases like other diseases; the 
symptoms and organ affected being known, but their precise 
pathology awaiting further discovery. 

Now then, linked together so beautifully in exact ana- 
tomical relations, we have the neurones that make up the 
great cerebro-spinal system of cerebrum, cerebellum, pons 
Varolii, basal ganglia, crura, medulla, cord and sensory and 
motor nerve connections. And the association and projection 
systems and neuroglia referred to, hold all in that normal 
healthy anatomical relation that makes the physiology of 
the cerebro-spinal system appear so beautifully and won- 
drously accurate and simple with all of its complexity. Break 
the connection anywhere and you have neuraxis or nerve 
center disease and thus recurs again the poetic aphorism, 

"From Nature's chain whatever link you strike, 
Tenth or ten thousandth, breaks the chain alike/' 

and you may have disease as grave as cerebro-spinal scle- 
rosis with its intention tremor or cerebral apoplexy with its 



ooma and paralysis, or neuroses so slight as the passing 
"t remor or evanescent paresis of stage fright. 

When the people, your future patients, come to under- 
stand this, as they will, with the diffusion of medical like 
«z»ther scientific truth among them, they will not wait till 
"the brain breaks under the burden of business or grief or 
'passion's excess or other mistakes of livjng and bad nervous 
^system care and management, before consulting you. They 
^arill seek medical counsel in time to avoid catastrophe to 
"the delicately wrought, yet wonderfully strong nervous 
system, considering the abusive strains to which it is sub- 
j ected and which it endures before it gives way to the 
T>ressure of adverse environment, in our modern strenuous 
Bife. 

The erroneous popular teaching that the mind, because 
i mmaterial, is independent of the body, and that will power, 
^xvhich is nothing less nor more than good or ill endowed 
psychic -neurone power, can do everything or almost every- 
thing, is responsible for the ignoring of the neurologist, the 
wieglect of timely attention to the needs of the nervous 
system and the gradual or sudden and fatal brain break- 
downs and needlessly early deaths among so many of our 
wnen of affairs, at the very time when they are most needed 
smd ought to do their best brain work. 

It will be your business to impress the danger of the 
reckless prodigal overstrain of psychic neurones and the 
importance of timely care of them on the people who 
employ you for wise and prudent counsel pertaining to their 
health. Man is a bundle of neurones and those people 
who speak of themselves as bundles of nerves, because 
they are so irritable, easily frightened, perturbed, sleepless 
or otherwise nervous, are bundles of unstable neurones 
which need neurological attention. They need their psychic 



64 

neurones looked after as much as the implements of their 
business need repairing from time to time. They need to 
be sent to pasture from time to time like their tired horses, 
or to the shop for repairs like their wagons or harness. 
Teach your patients to be sensibly good to themselves and 
kindly and timely considerate of their neurones and they will 
be good to you, by employing your aid more, and kind to 
themselves, by giving you a chance for timely attention 
to themselves, when you may save them from those grave 
neuropathic calamities that now needlessly befall so many 
good men in all lines of strenuous action. 

The brain is made an anatomical and a physiological 
whole, and the spinal cord likewise, by the association and 
projection communicating systems of the brain and cord. You 
see you are to have great use for this knowledge, for disease 
damages or dissevers these normal relations. When it only 
disturbs or damages relations you have less serious lesions 
to deal with than when disease destroys relations. Tremors, 
tremulousness, feebleness, perverted movements come from 
disturbances of neuraxial relations short of destruction. 

Destruction makes even perverted function impossible 
and then you have paralysis. The destroyed motor centre 
makes motion impossible. The motor center touched by disease 
short of destruction that is irritated, gives spasm or contrac- 
tion, or alternating contraction and relaxation, which is convul- 
sion or tremor, because there remain undestroyed neurones to 
be disordered in action and intact projection tracts to convey 
disordered action outward from the centers of spine or cord. If 
the projection tracts are impaired you have impaired or altered 
action, but still action; if destroyed you have no action or 
paralysis; if partly destroyed you have partial paralysis or 
paresis. Refer in the study of this interesting projection fiber 
system to Figs. 14, 24, 33 and compare with 13 and 22.. 



65 

We have already seen and shall presently see more 
*rom other illustrations as well as this one, how the projec- 
tion fibers converge from the cortex to form the corpora 
striata and pass downward and outward in the crura and 
<zord tracts. Some of these fibers are fine and some are 
coarse, some longer and some shorter. The projection fibers 
belong mainly to the neuraxis, connecting brain with spinal 
<3ord centers. The association fibers described in the fol- 
* owing and preceding illustrations belong to the brain. 

Ford Robertson has called attention to the fact which 

*~ie has brought out by the platinum method of staining that 

* 'the structures described as neuroglia do not consist of one 

tissue, as has been generally believed, but are composed of 

^t least two kinds of cell elements of which the origin, 

■~»orphology, functions and behavior in morbid conditions are 

^^ntirely distinct." The advanced student may be interested 

m n the above note and Robertson's plates xviii, xix and xx, 

fcut you will not be examined on this subdivision of the 

■neuroglia in the final examinations. Andreisen, whom he 

quotes, has described the neuroglia as made up of separate 

^piblastic and mesoblastic elements but somewhat different 

*"rom those observed by W. Ford Robertson, who suggests 

*fchat the neuroglia containing epiblastic elements should 

only be called neuroglia and those containing mesoblastic 

elements should be termed mesoglia cells, illustration of 

Which you may see by reference to Robertson's plate xx. 

But though Robertson makes a beautiful demonstration of 

Viis contention by his platinum method, as the illustrations 

establish, we shall call them all neuroglia. They are both 

engaged in similar business, these mesoglia and neuroglia 

or blastoglia and mesoglia, if you choose, viz.: that of 

sustaining the neurones at their respective stations and 

posts of duty. Different parts of the neuroglia do, 



66 

however, seem to behave differently under disease but as 
they belong to some nerve center and are manifest with its 
disease 1 will not discuss either mesoglial or blastoglial 
diseases, as 1 would term disease of the remainder of the 
neuroglia for purposes of distinction. 

We cannot dwell longer among the neurones and neu- 
roglia. My vocation as educator is to lead you into the 
ways of knowledge necessary for your advancement in the 
essentials of neurology. It is your duty to go on farther in 
these pathways or in new ones which you may mark out 
for yourselves. 

After you shall have become advanced students of cytol- 
ogy you may have the inclination to take up this subject 
and pursue it in extenso. We cannot go further now. Ford 
Robertson concedes that his mesoglia are about as numer- 
ous as the neuroglia and they are certainly so closely mixed 
up and interlaced with them that we consider them together. 
So when 1 talk about neuroglia or quiz you upon the sub- 
ject 1 shall mean to include all under the one term neuroglia 
for the present. Robertson aptly calls them "the guy 
ropes for the capillaries" as well as the supports of the 
nerve cells and prolongations, and you may see the neu- 
roglia often attached to the capillaries. He says they are 
repair tissues, for the brain is like tissues in other parts of 
the body and this is in harmony with Bevan Lewis' suste- 
nance idea. Here our study of the nutrient network of the 
neurones must close for the present. The further illustra- 
tions which follow must suffice as objective lessons in lieu 
of another lecture on the subject. 

The neuraxones or axis-cylinder processes of neurones 
are either long or short, terminating close to their parent 
neurones or far from them. The latter are typified in the 
pyramidal neurones or projection cells of Shaeffer, which 



67 

send their neuraxones down into the cord or across the brain, 
through the corpus callosum. They are chiefly motor im- 
pulse cells. The shorter neurones are called intermediary 
cells and are connecting neurones to other neurones. They 
are a type of Golgi cells, so called because described by 
this great investigator in cytology. He thought they were 
exclusively sensory cells, a view not generally entertained 
now, but I am not sure this view ought to have been 
abandoned. The shape of the brain cortex neurones, besides 
being designated as pyramidal, apolar, bi-polar, multi-polar, 
etc., are also called stellate, ovoid, etc., but Meynert's 
division into pyramidal, mixed granule form and spindle- 
shaped about covers the varieties in conformation. 

The fibrae propria?, connecting neighboring convolutions 
of the cortex, and the longer commissural fibers which connect 
more distant cortex areas with each other, appear somewhat 
as in illustrations Figs. 22 and 35. They and other fibers 
make possible the traversing of a cortex irritation, like that 
of an epilepsia, for instance, from one point, the point of 
the initial aura, for example, to others distant in the brain. 
But they do not appear quite so plain under the microscope 
as in these diagrams. Artifacts, that is, artificial or after- 
death products resulting from handling of the brain, tissue, 
rupture, etc., post-mortem appear, under the lense, to in- 
terrupt and otherwise obscure the appearances of these 
important fibers. This accounts for the diagrams of different 
microscopists varying a little. But in the main their out- 
lines are in accord, those of that excellent one by one of 
the latest observers, Vangehuchten, with the comparatively 
small number traced and named by Edinger, whose classical 
and standard diagram is to be found in many of your text- 
books, and which shows the following tracts. It will be 
easy for you to become familiar with all the other details 



68 

in neurocytology. But you are glad, no doubt, that the 
number is so limited. 

These tracts are the uncinate or hook- shaped fibers 
going from the cortex of the temporal lobe forward along 
the ventral border of the insula into the ventral regions 
of the frontal lobe: the arcuate fibers, or fasculi arcuati, 
which pass over the dorsal part of the insula from the most 
posterior portion of the temporal lobe to the cortex of the 
parietal and frontal lobes. Next the cingulum % a long tract 
that runs in the marginal gyrus — gyrus fornicatus — from 
the cortex of the cornu ammonis to the most ventral 
region of the frontal lobe, including the olfactory lobe in 
the dog, rabbit, etc. Then we have the inferior longitudinal 
fibers running antero-posteriorly across the brain and con- 
necting temporal with occipital lobes and the fronto-occipital 
fibers of the fasculus fronto-occipitalis, as Edinger describes 
them, "arising from the medullary covering of the posterior 
and lateral horns of the ventricle, its fibers passing forward 
as a well -defined bundle external to the lateral ventricle," 
beneath the corpus callosum and on the dorsal edge of the 
nucleus caudatus. The arcuate fibers and the fibers of the 
cingulum belting the corpus callosum are all antero- posterior 
fibers. Almost all of the inter- lateral or crossed commissural 
fibers pass transversely through the corpus callosum or 
anterior commissure or crossing, and are called in the litera- 
ture, transverse callosal or transverse commissural fibers or 
fasciculi. There are other lesser fibers called forceps major, 
forceps minor and the tapetum corporis callosi or the band 
or tape shape bundle of fibers which pass in either hemi- 
sphere through the corpus callosum to the temporal lobe. 
The libers of the forceps major come from the occipital 
lobe, run in the corpus callosum and surround the posterior 
horn of the lateral ventricle like a cap, resembling some- 



^*^hat the fibrae propria?. "That portion of the corpus callo- 
sum passing into the temporal lobe on the lateral side of 
"the inferior horn of the lateral ventricle is called the forceps 
minor." 

These terms are used for the purpose of minute de- 
scription by brain histologists. You do not need to carry 
tihiem all continuously in your minds, but only to know 
'Where to find them when referring to the plates of the 
t:ext- books in studying minute brain descriptions. Remem- 
ber, however, the general direction and arrangement of the 
connection and projection fibers of the brain. And their 
courses go crosswise, lengthwise, obliquely and downward 
in the brain, through and over the corpus callosum, about 
and over the ventricles, to and through the basal ganglia, 
the longer tracts going down the cord. They are inter- 
cerebral, circumgyral, corticle, spinal, etc., as their courses 
studied in a case of apoplexia, post-mortem for instance, 
with Marchi osmium stain will often show you, especially 
in the tracing of the downward or descending degenerations 
of this cerebral disease. 

1 can not here enter more minutely into this branch of 
a most interesting subject. But 1 commend to you for 
vacation reading, in connection with this and preceding 
lectures, Meynert, translated by B. Sachs, of New York, 
on the Anatomy, Physiology and Nutrition of the Brain; 
Obersteiner, Edinger, Robertson, Morrison, Lewis and others 
already mentioned. 

The tumor most peculiar to the neurologlial network 
bears the name of this structure and is called glioma. The 
neuroglia of the brain and pons is the most frequent seat 
of this form of brain tumor. 

Inflammation and gummata are most common in the 
meninges and arteries. 



NEUROGLIA CHANGES IN CEREBRAL DISEASE. 
(After Ford Robertson.) 



FIG. 43. 



• • • 



• -•• 



•• • 



00 ■ * , 




. rf 






'«. • • • . 

i* • .. ' • * * ' • . * 



\ 



* 




DESCRIPTION OF FIG. 43. 

Fig. 11. Outermost layer of normal cerebral cortex (human) (x300). 
The dark, rounded nuclei, are mostly those of neuroglia cells. 

Fig. 12. Outermost layer of cerebral cortex from a case of advanced 
general paralysis, showing great hypertrophy of neuroglia, and thickening 
of the vessel walls. (x300.) 

Fig. 13. Outermost layer of cerebral cortex from a case of senile in- 
sanity, showing a moderate degree of hypertrophy and hyperplasia of the 
neuroglia, sub-pial felting (containing some colloid bodies), and thickening 
of vessels. The neuroglia cells are pigmented. (x300.) 

Fig. 14. Outermost layer of cerebral cortex from a case of epileptic 
insanity, showing slight hypertrophy of neuroglia, together with marked 
sub-pial felting, (x 300. ) 

Fig. 15. Two greatly hypertrophied neuroglia cells from the tissues 
adjoining a small secondary carcinomatous nodule in the cerebrum. Analine 
black, fresh mathoJ. (x50D.) Tumors, localized centers of inflammation, 
and recent softenings are generally surrounded by a broad zone of neuroglia 
cells of this kind. They are swollen to several times their normal size, 
and it can be recognized that many of them are divided. Note the dendritic 
branching of the processes. 

Fig. 16. Greatly hypertrophied neuroglia cells, surrounding an arte- 
riole in the deepest layer of the cortex, in a case of advanced general 
paralysis. Analine black, fresh method. (x500.) The arteriole shows 
periarteritis. The nerve cells have for the most part disappeared. 

FIG. 44. 
£>«.??•«¥ «*w5 Uv&rtfvotv o£ TUw 




„ _ _ Nec»oolh Culs or tkb Bkaix, tbui Rzlatiov* to m 

KM0>Tmiu; a&ao na BoaraTAccLA* Processes or m Emtkcual Cblls or t«« 
Urrui, Vnrmcu ICarchO. A % Epithelial cells Uoln* lateral ventricle; o, process of 
matt, **yktar<«Bsun>ciiaceU;c, Mood-vessel. 



CHAPTER VII. 

HEAD HEAT IN BRAIN DISEASE, CEREBRAL THERMOMETRY, AND 
CEPHALIC GALVANIZATION — THEIR VALUE IN 
DIAGNOSIS AND PRACTICE. 



Temperature taking since Wunderlich and Liebermeister 
has become in medicine a routine proceeding and the clin- 
ical thermometer is almost as familiar as the tongue and 
pulse in practice. From sublingual axillary and rectal tem- 
perature taking and the testing of the palmar heat by Couty, 
the practice has passed in clinical neurology through the 
studies of Broca, Alvarengo, Maragliano, Sepelli, Albers, 
Gray, Amidon, Mills, Lombard and others to the head. 

In that great Italian asylum for the insane at Reggio 
Amelia. where chiefly brain diseases in their extreme and 
most calamitous degree come under notice, the two distin- 
guished Italian neurologists and alienists of Reggio Amelia 
made painstaking studies of cerebral thermometry in paresis 
or general paralysis of the insane, melancholia, furious 
mania, etc. These studies will interest you, for these cases 
will often come under your notice as well as all degrees 
below them of mental impairment, down to the morbid psy- 
chic caprices and hallucinations of hysteria and the morbid 
fears of mysophobia and neurasthenia. 

Paolo Bert found by self-experimentation when the 
temperature of the brain was not equal on both sides, it 
was higher over the left hemisphere in the frontal region. 



T~ lie heat was also highest on the left during intellectual 
^ncrtivity. Others have confirmed this observation. Mills 
f r <^* *md augmented temperature in a tumor of the right frontal 
I c> !>e which was found on autopsy to have destroyed the 
3. anterior half of the first and second convolutions, part of 
th^ corpus callosum and gyrus fornicatus, but it did not 
ir-m^olve the speech center of Broca, hence though halluci- 
nated, mentally enfeebled, and with headache, vomiting and 
tia-ving nystagmus, impaired vision, olfaction and general 
sensation with dilated and fixed pupils, his speech power 
Tarsis intact. He had no aphasia. This is important for you 
*» note with reference to a discussion of speech center 
disease or aphasia later in this course. 

My lamented friend, Landon Carter Gray, early put on 

record a lesion which he claims was the first intracranial 

tumor diagnosticated by cerebral thermometry. It was a 

glioma. The clinical symptoms pointed to the base but he 

located the tumor at the lateral aspect of the cerebrum and 

ti^e autopsy confirmed the thermometric diagnosis. 

The average temperature of the right side of the head, 
the side of the tumor, was 99°52' ; of the left side it was 
96°1<S\ and of the whole head 97°84'. Since then Mills 
h*s reported one case of frontal tumor and a gumma of the 
a*pus callosum diagnosticated in part by local head heat 
increase; Eskridge, a tumor of the cerebellum with monocu- 
k* hemianopsia, and Putnam Jacobt a tubercular meningitis 
** the same way. 

lUragfiano proved the thermometers could indicate 
x^itefy the temperature of the skull by filling the latter 
*tth water at different tempera* ures arid testing thermomet- 
rcaBy the temperature through the scalp and hiir which he 
Af not remove from the jrar.i-rr.. The trT.perat *r~ ^f the 

heat on the scalp \-*rUce were 





shown by simultaneous water and surface heat measui 
ment^ to correspond. 

But do not be misled into concluding that, with no cran >W 
increase of temperature existing, there can be no crafl *^ 
disease. I have had one or two such cases myself. * 

brain tumor may exceptionally develop so slowlv as to rtrf^™ 1 
excite heat developing irritation for a time. 

Maragliano, Sepelli and Broca selected points behind tM - hr 
external orbital epiphysis for the frontal region; above tW 
insertion of the ear for the temporal region; and along siu^ ^ e 
the median line for the occipital region. The six centigrac^^** e 
thermometers used by them "for better isolation, were cov-^^*" 
ered with a little carded cotton wool an J were fixed t^ 
means of a circular bandage, special care being taken Um 
tlie bulbs were not pressed against the surface of the era 
ilium. In the women the hairs were accurately divided, 
that the elongated bulb of the thermometer might com- 
into close contact with the scalp. The duration of th^ 
application was half an hour for each patient. Appti< 
was made in the axilla and the rectum in immediate suc- 
cession to those on the head, with the view of avoiding 
any false interpretation of the latter; * * febrile states ma> 
sometimes interpose, in patients examined, and the aug- 
mented temperature of the cranium then noted, might he 
attributed to local influence, whilst, on the contrary, it was 
but a manifestation of the system." 

The authors introduce three tables which we refrain 
from reproducing, substituting this summary, as the temper- 
ature of the normal brain as measured through the cranium 
is from h% to A% degrees less than it is in the axilla or 

im. "The mean temperature of the head in these 
examinations reached its maximum in furious mania (mania 
confurore), 36.89; and in a progressively decreasing line, in 



73 

lyp&mania agitata, 36.81; in general paresis fparalisi progres- 
siv&^J, 36.63; in dementia agitata, 36.45; in imbecility and 
idiocr^v, 36.34; in mania, without fury, 36.30; in simple lype- 
mania, 36.17; and finally, in tranquil dementia, 36.03, cen- 
tigrade markings." The easiest way of turning these into 
F^Hr^nheit is to multiply by 2; deduct one-tenth the product 
and then add 32°. Thus 36.89x2=73.78-1-10 = 66.40, 
plus 32° = 98.40. 

There were differences between Maragliano's, Gray's, 

Broca's and Sepelli's results due somewhat to the different 

se ^son at which their respective observations were made in 

Jun^, July and August; Broca's and Gray's being in colder 

we at:lier, Sepelli and Maragliano remind us (see Alienist 

and Neurologist as previously quoted) that "Wunderlich 

alluding to the various precautions to be taken in thermo- 

me tric practice, observes that in observations made in sum- 

mer » it may be useful to take account of the surrounding 

* e n-ip er qture and that if such an observance is of value in 

axili ar y and rectal thermometry, it must be still more so in 

rel ation to that on the head." 

SH **ELLI'S CEREBRAL THERMOMETRY MEASUREMENTS. 

1st. The medium temperature of the sane man is, 

ac cording to Sepelli's thermometric measurements, "36.13 for 

th fc left side and 36.08 for the right— 36.10 for the whole 

*^ad. As to the diverse regions the means of the frontal 

l °bes are 36.20 for the left and 36.15 for the right; of the 

Parietal, 36.18 for the left and 36.15 for the right; of the 

°ccipital, 36.13 for the left and 36.08 for the right." 

2d. "In the insane, except in simple lypemania and 
dementia, the mean temperature of the head is above normal, 
the highest degree being reached by mania with fury 
(36.89) ; lypemania next (36.81), then general paralysis 



CHAPTER VII. 

HEAD HEAT IN BRAIN DISEASE, CEREBRAL THERMOMETRY, AND 
CEPHALIC GALVANIZATION — THEIR VALUE IN 
DIAGNOSIS AND PRACTICE. 

Temperature taking since Wunderlich and Liebermeister 
has become in medicine a routine proceeding and the clin- 
ical thermometer is almost as familiar as the tongue and 
pulse in practice. From sublingual axillary and rectal tem- 
perature taking and the testing of the palmar heat by Couty, 
the practice has passed in clinical neurology through the 
studies of Broca, Alvarengo, Maragliano, Sepelli, Albers, 
Gray, Amidon, Mills, Lombard and others to the head. 

In that great Italian asylum for the insane at Reggio 
Amelia. where chiefly brain diseases in their extreme and 
most calamitous degree come under notice, the two distin- 
guished Italian neurologists and alienists of Reggio Amelia 
made painstaking studies of cerebral thermometry in paresis 
or general paralysis of the insane, melancholia, furious 
mania, etc. These studies will interest you, for these cases 
will often come under your notice as well as all degrees 
below them of mental impairment, down to the morbid psy- 
chic caprices and hallucinations of hysteria and the morbid 
fears of mysophobia and neurasthenia. 

Paolo Bert found by self-experimentation when the 
temperature of the brain was not equal on both sides, it 
was higher over the left hemisphere in the frontal region. 

[70] 



DESCRIPTION OF FIG. 43. 

Fig. 11. Outermost layer of normal cerebral cortex (human) (x300). 
The dark, rounded nuclei are mostly those of neuroglia cells. 

Fig. 12. Outermost layer of cerebral cortex from a case of advanced 
general paralysis, showing great hypertrophy of neuroglia, and thickening 
of the vessel walls. (x300.) 

Fig. 13. Outermost layer of cerebral cortex from a case of senile in- 
sanity, showing a moderate degree of hypertrophy and hyperplasia of the 
neuroglia, sub-pial felting (containing some colloid bodies), and thickening 
of vessels. The neuroglia cells are pigmented. (x300.) 

Fig. 14. Outermost layer of cerebral cortex from a case of epileptic 
insanity, showing slight hypertrophy of neuroglia, together with marked 
sub-pial felting. (x300.) 

Fig. 15. Two greatly hypertrophied neuroglia cells from the tissues 
adjoining a small secondary carcinomatous nodule in the cerebrum. Analine 
black, fresh msthoi. (x50D.) Tumors, localized centers of inflammation, 
and recent softenings are generally surrounded by a broad zone of neuroglia 
cells of this kind. They are swollen to several times their normal size, 
and it can be recognized that many of them are divided. Note the dendritic 
branching of the processes. 

Fig. 16. Greatly hypertrophied neuroglia cells, surrounding an arte- 
riole in the deepest layer of the cortex, in a case of advanced general 
paralysis. Analine black, fresh method. (x500.) The arteriole shows 
periarteritis. The nerve cells have for the most part disappeared. 

FIG. 44. 




Ncraootxi Cuxs or th» Brain, tikis Rslattoks to th« 
Buod-Ywiu; iiio tsb SuiTKMTAcuLAn Processes or rts Etithsual Ckljls or th* 
t^mu, Vevthclb TOarchO. A, Epithelial cells lining lateral ventricle; a, process or 
sum, * epl^ or neuroglia beU;c, blood-vessel 



CHAPTER VII. 

HEAD HEAT IN BRAIN DISEASE, CEREBRAL THERMOMETRY, AND 
CEPHALIC GALVANIZATION — THEIR VALUE IN 
DIAGNOSIS AND PRACTICE. 



Temperature taking since Wunderlich and Liebermeister 
has become in medicine a routine proceeding and the clin- 
ical thermometer is almost as familiar as the tongue and 
pulse in practice. From sublingual axillary and rectal tem- 
perature taking and the testing of the palmar heat by Couty, 
the practice has passed in clinical neurology through the 
studies of Broca, Alvarengo, Maragliano, Sepelli, Albers, 
Gray, Amidon, Mills, Lombard and others to the head. 

In that great Italian asylum for the insane at Reggio 
Amelia. where chiefly brain diseases in their extreme and 
most calamitous degree come under notice, the two distin- 
guished Italian neurologists and alienists of Reggio Amelia 
made painstaking studies of cerebral thermometry in paresis 
or general paralysis of the insane, melancholia, furious 
mania, etc. These studies will interest you, for these cases 
will often come under your notice as well as all degrees 
below them of mental impairment, down to the morbid psy- 
chic caprices and hallucinations of hysteria and the morbid 
fears of mysophobia and neurasthenia. 

Paolo Bert found by self-experimentation when the 
temperature of the brain was not equal on both sides, it 
was higher over the left hemisphere in the frontal region. 



71 

The hjeat was also highest on the left during intellectual 
activity. Others have confirmed this observation. Mills 
found augmented temperature in a tumor of the right frontal 
lobe vrhich was found on autopsy to have destroyed the 
anterior half of the first and second convolutions, part of 
the crorpus callosum and gyrus fornicatus, but it did not 
Evolve the speech center of Broca, hence though halluci- 
nated, mentally enfeebled, and with headache, vomiting and 
having nystagmus, impaired vision, olfaction and general 
sensation with dilated and fixed pupils, his speech power 
Was intact. He had no aphasia. This is important for you 
to note with reference to a discussion of speech center 
" ls ^ase or aphasia later in this course. 

My lamented friend, Landon Carter Gray, early put on 
record a lesion which he claims was the first intracranial 
tumor diagnosticated by cerebral thermometry. It was a 
glioma. The clinical symptoms pointed to the base but he 
located the tumor at the lateral aspect of the cerebrum and 
"* e autopsy confirmed the thermometric diagnosis. 

The average temperature of the right side of the head, 

"* e side of the tumor, was 99°52'; of the left side it was 

96 °16 / , and of the whole head 97°84 / . Since then Mills 

"as reported one case of frontal tumor and a gumma of the 

COr Pus callosum diagnosticated in part by local head heat 

ln crease; Eskridge, a tumor of the cerebellum with monocu- 

ar hemianopsia, and Putnam Jacobi a tubercular meningitis 

ln the same way. 

Maragliano proved the thermometers could indicate 
a <*urately the temperature of the skull by filling the latter 
With water at different temperatures and testing thermomet- 
rically the temperature through the scalp and hair which he 
did not remove from the cranium. The temperature of the 
water in the skull and the heat on the scalp surface were 



NEUROGLIA CHANGES IN CEREHRA1. DISEASE. 
(After Ford Robertson.) 

FIG. 43. 



- • •• •• • •• * • • • # 



• # • • • 



• • • *. • 

• • •* 

• . * • 






•• ••• •• 



»*!» 



? % » 



V 



> 



\ 



J . 




DESCRIPTION OF FIG. 43. 

Fig. 11. Outermost layer of normal cerebral cortex (human) (x300). 
The dark, rounded nuclei are mostly those of neuroglia cells. 

Fig. 12. Outermost layer of cerebral cortex from a case ot advanced 
general paralysis, showing great hypertrophy of neuroglia, and thickening 
of the vessel walls. (x300.) 

Fig. 13. Outermost layer of cerebral cortex from a case of senile in- 
sanity, showing a moderate degree of hypertrophy and hyperplasia of the 
neuroglia, sub-pial felting (containing some colloid bodies), and thickening 
of vessels. The neuroglia cells are pigmented. (x300.) 

Fig. 14. Outermost layer of cerebral cortex from a case of epileptic 
insanity, showing slight hypertrophy of neuroglia, together with marked 
sub-pial felting. (x300.) 

Fig. 15. Two greatly hypertrophied neuroglia cells from the tissues 
adjoining a small secondary carcinomatous nodule in the cerebrum. Analine 
black, fresh method. (x50D.) Tumors, localized centers of inflammation, 
and recent softenings are generally surrounded by a broad zone of neuroglia 
cells of this kind. They are swollen to several times their normal size, 
and it can be recognized that many of them are divided. Note the dendritic 
branching of the processes. 

Fig. 16. Greatly hypertrophied neuroglia cells, surrounding an arte- 
riole in the deepest layer of the cortex, in a case of advanced general 
paralysis. Analine black, fresh method. (x500.) The arteriole shows 
periarteritis. The nerve cells have for the most part disappeared. 

FIG. 44. 
Sw??**? a«j UvOri'tVotv o? TXewvvMS 




Keckoqua Cells or Tin Baux. their Relattows to the 
Bcaob-Vobjclb; alio tii ScsTEXTAccLta Processes or t«b Epithelial. Cell* or the 
L*tt-ul Vbhthcu Olarchl). A, Epithelial cells Unit* lateral ventricle; a, process of 
sam , a, spider or neuroglia cell; c, Mood- vessel. 



CHAPTER VII. 

HEAD HEAT IN BRAIN DISEASE, CEREBRAL THERMOMETRY, AND 
CEPHALIC GALVANIZATION — THEIR VALUE IN 
DIAGNOSIS AND PRACTICE. 



Temperature taking since Wunderlich and Liebermeister 
has become in medicine a routine proceeding and the clin- 
ical thermometer is almost as familiar as the tongue and 
pulse in practice. From sublingual axillary and rectal tem- 
perature taking and the testing of the palmar heat by Couty, 
the practice has passed in clinical neurology through the 
studies of Broca, Alvarengo, Maragliano, Sepelli, Albers, 
Gray, Amidon, Mills, Lombard and others to the head. 

In that great Italian asylum for the insane at Reggio 
Amelia. where chiefly brain diseases in their extreme and 
most calamitous degree come under notice, the two distin- 
guished Italian neurologists and alienists of Reggio Amelia 
made painstaking studies of cerebral thermometry in paresis 
or general paralysis of the insane, melancholia, furious 
mania, etc. These studies will interest you, for these cases 
will often come under your notice as well as all degrees 
below them of mental impairment, down to the morbid psy- 
chic caprices and hallucinations of hysteria and the morbid 
fears of mysophobia and neurasthenia. 

Paolo Bert found by self-experimentation when the 
temperature of the brain was not equal on both sides, it 
was higher over the left hemisphere in the frontal region. 



71 

The heat was also highest on the left during intellectual 
activity. Others have confirmed this observation. Mills 
found augmented temperature in a tumor of the right frontal 
lobe which was found on autopsy to have destroyed the 
anterior half of the first and second convolutions, part of 
the corpus callosum and gyrus fornicatus, but it did not 
involve the speech center of Broca, hence though halluci- 
nated, mentally enfeebled, and with headache, vomiting and 
having nystagmus, impaired vision, olfaction and general 
sensation with dilated and fixed pupils, his speech power 
was intact. He had no aphasia. This is important for you 
to note with reference to a discussion of speech center 
disease or aphasia later in this course. 

My lamented friend, Landon Carter Gray, early put on 
record a lesion which he claims was the first intracranial 
tumor diagnosticated by cerebral thermometry. It was a 
glioma. The clinical symptoms pointed to the base but he 
located the tumor at the lateral aspect of the cerebrum and 
the autopsy confirmed the thermometric diagnosis. 

The average temperature of the right side of the head, 
the side of the tumor, was 99^52'; of the left side it was 
96°16', and of the whole head 97°84 / . Since then Mills 
has reported one case of frontal tumor and a gumma of the 
corpus callosum diagnosticated in part by local head heat 
increase; Eskridge, a tumor of the cerebellum with monocu- 
lar hemianopsia, and Putnam Jacobi a tubercular meningitis 
in the same way. 

Maragliano proved the thermometers could indicate 
accurately the temperature of the skull by filling the latter 
with water at different temperatures and testing thermomet- 
rically the temperature through the scalp and hair which he 
did not remove from the cranium. The temperature of the 
water in the skull and the heat on the scalp surface were 



72 

shown by simultaneous water and surface heat measure- 
ments to correspond. 

But do not be misled into concluding that, with no cranial 
increase of temperature existing, there can be no cranial 
disease. I have had one or two such cases myself. A 
brain tumor may exceptionally develop so slowlv as to not 
excite heat developing irritation for a time. 

Maragliano, Sepelli and Broca selected points behind the 
external orbital epiphysis for the frontal region; above the 
insertion of the ear for the temporal region; and along side 
the median line for the occipital region. The six centigrade 
thermometers used by them "for better isolation, were cov- 
ered with a little carded cotton wool and were fixed by 
means of a circular bandage, special care being taken that 
the bulbs were not pressed against the surface of the cra- 
nium. In the women the hairs were accurately divided, so 
that the elongated bulb of the thermometer might come 
into close contact with the scalp. The duraticjn of the 
application was half an hour for each patient. Application 
was made in the axilla and the rectum in immediate suc- 
cession to those on the head, with the view of avoiding 
any false interpretation of the latter; * * febrile states may 
sometimes interpose, in patients examined, and the aug- 
mented temperature of the cranium then noted, might be 
attributed to local influence, whilst, on the contrary, it was 
but a manifestation of the system." 

The authors introduce three tables which we refrain 
from reproducing, substituting this summary, as the temper- 
ature of the normal brain as measured through the cranium 
is from 3>£ to 4)4 degrees less than it is in the axilla or 
rectum. "The mean temperature of the head in these 
examinations reached its maximum in furious mania (mania 
confurore), 30.89; and in a progressively decreasing line, in 



73 

lypemania agitata, 36.81; in general paresis (paralisi progres- 
siva), 36.63; in dementia agitata, 36.45; in imbecility and 
idiocy, 36.34; in mania, without fury, 36.30; in simple lype- 
mania, 36.17; and finally, in tranquil dementia, 36.03, cen- 
tigrade markings." The easiest way of turning these into 
Fahrenheit is to multiply by 2; deduct one-tenth the product 
and then add 32°. Thus 36.89x2=73.78-1-10 = 66.40, 
plus 32° = 98.40. 

There were differences between Maragliano's, Gray's, 
Broca's and Sepelli's results due somewhat to the different 
season at which their respective observations were made in 
June, July and August; Broca's and Gray's being in colder 
weather, Sepelli and Maragliano remind us (see Alienist 
and Neurologist as previously quoted) that "Wunderlich 
alluding to the various precautions to be taken in thermo- 
metric practice, observes that in observations made in sum- 
mer, it may be useful to take account of the surrounding 
temperature and that if such an observance is of value in 
axillary and rectal thermometry, it must be still more so in 
relation to that on the head." 

SEPELLI'S CEREBRAL THERMOMETRY MEASUREMENTS. 

1st. The medium temperature of the sane man is, 
according to Sepelli's thermometric measurements, "36.13 for 
the left side and 36.08 for the right— 36.10 for the whole 
head. As to the diverse regions the means of the frontal 
lobes are 36.20 for the left and 36.15 for the right; of the 
parietal, 36.18 for the left and 36.15 for the right; of the 
occipital, 36.13 for the left and 36.08 for the right." 

2d. "In the insane, except in simple lypemania and 
dementia, the mean temperature of the head is above normal, 
the highest degree being reached by mania with fury 
(36.89) ; lypemania next (36.81), then general paralysis 



74 

(36.63); dementia agitata (36.45); imbecility and idiotism 
(36.54); mania without fury (36.30); simple dementia 
(36.03). 

3d. "In all the forms of mental disease the occipital 
lobes, as in the sane man, give a temperature lower than 
the other lobes; the temperature of the frontal lobes, which 
equals that of the parietal in dementia agitata, imbecility 
and idiotism, excels it in mania, simple lypemania and 
simple dementia, whilst in general paralysis and lypemania 
agitata the temperature of the parietal lobes is higher than 
that of the frontal. 

4th. In all the principal groups of mental diseases, the 
mean of the two halves of the head is almost equal, except 
in congenital forms. Here the right half presents figures 
higher than those of the left. 

(This tends to substantiate Wigan's idea that it is 
when the entire brain is involved and the balancing and 
correcting influence of the opposite hemisphere is impaired 
by disease that insanity appears.— Hughes.) 

5th. The results of cerebral thermometry, placed in 
accord with what is known of the pathological anatomy of 
insanity, confirm the fact that in general paralysis, mania 
and divers periods of exaltation, which are frequently man- 
ifested even in forms of depression and mental enfeeblement, 
there exists a state of hyperemia of the brain. 

6th. The surrounding temperature has a notable influ- 
ence on the results of cerebral thermometry. 

7th. The general temperature of the body in the insane, 
taken in the axilla or in the rectum, is greater in lypemania 
agitata and mania furiosa, and in decreasing order it pro- 
ceeds, diminishing in general paralysis, dementia agitata, 
mania without fury, imbecility and idiocy, tranquil dementia 
and simple lypemania/' 



75 

These results were obtained at the insane asylum of 
Reggio Emilia Sept. 20, 1878. They have not been inval- 
idated by later observations and have served me well in 
the clinical study of brain disease as they will serve you. 

Professor E. Maragliano read to the medical congress at 
Pisa September 26, 1879, the result of a series of experi- 
ments made by him in his School of General Pathology, in 
Genoa. He first, by means of experimental investigations, 
sought to eliminate whatever doubt might arise as regards 
the capacity of the cranial walls to transmit promptly in 
thermometers placed on the exterior, the internal oscillations 
of temperature. With this view he applied thermometers to 
the exterior of different cranial envelopments, which were 
filled with water, at various temperatures, and he was able . 
to see that the thermometers on the outside rapidly followed 
the oscillations shown by those placed inside. 

He next studied the physiological and pathological tem- 
perature, and that present during chloralic sleep. The 
conclusions which he drew from these researches were the 
following: 

1st. The thermometers applied to the cranial integu- 
ments faithfully follow the thermal internal oscillations. 

2d. The cerebral temperature revealed in this manner 
in physiological conditions is shown more elevated on the 
left than on the right side, especially by thermometers 
placed near the frontal region. (The left is the driving side 
of the brain, or, preferably, active side ordinarily. — H.) 

3d. The degree of temperature varies according to age 
and sex. 

4th. In the same individual there are presented in the 
course of a day, from time to time, elevations or depressions 
which do not exceed half a degree. 

5th. The cerebral temperature may have relations to 



76 

pathology, but relatively to the conditions existing between 
the two sides, or between points on the same side. 

6th. To have absolute value, elevations or depressions, 
at least one degree above the physiological mean, are 
called for. 

7th. In cerebral embolism there is a diminution in the 
lobe irrigated by the plugged vessel, from which may be 
deduced an important diagnostic criterion. 

8th. During the chloral sleep there is a constant dimi- 
nution of the cerebral temperature. (Suggesting arteriole 
contraction. — H.) 

Thus you " see the importance and utility of cerebral 
thermometry in brain disease has been placed beyond doubt 
by Maragliano, Sepelli, Broca, Clouston, Gray, Mills, Voisin 
and many others. It is an element of diagnosis as Voisin 
claimed "matching in value that of the stethoscope in dis- 
eases of the chest." 

In Voisin's experiments on healthy brains the maximum 
figure for the cranium never exceeded 36° (96.8 F.) even 
when the brain was in a state of functional activity, and 
with diminution of this, the cerebral temperature descended 
concurrently to a lower figure. Voisin, Maragliano and Sepelli 
proved cranial hyperemia in general paralysis and in all of 
the cases of insanity with maniacal delirium, also in hyper- 
emia by cranial thermometry. 

The case described by Gray of cerebral thermometry, 
already referred to, was that of a woman aged 34, in which 
a pupillary stasis, paroxysms of pain in the temporal and 
superciliary regions, nausea, vomiting, ptosis and paralysis 
of the ocular muscles, had led the physician to form the 
diagnosis of intercranial tumors, situate at the base of the 
brain; Gray having the opportunity of observing it applied 



77 

the thermometer on various parts of the head and obtained 
the following results: 

LEFT. RIGHT. 

Frontal region 95° 75 98° 33 

Parietal " 95 99 75 

Occipital " ..96 75 100 60 

Resting on these data, he was able to conclude that 
the lesion must be extended from the base of the Sylvian 
fissure backwards along the right occipital lobe. The 
autopsy showed the existence of a gliomatuous tumor, situ- 
ate between the horizontal or posterior branch of the Sylvian 
fissure, and the parallel one of the right side, whilst the 
entire occipital lobe- was converted into a colloid mass, 
extremely vascular. The meninges were unaltered. (The 
above and the following are taken from Maragliano and 
Sepelli's paper in Revista Spermentali and translated into the 
Alienist and Neurologist, vol. 1, nos. 1 and 2.)* 

The other case, communicated to the Philadelphia Path- 
ological Society by Dr. Mills, on November 14th, was that 
of a man aged 36, in which the principal symptoms were 
intense headache, vomiting, mental enfeeblement, hallucina- 
tions, but without delirium, no disturbance of the speech, 
slight paralysis of the left arm, weakness in the lower 
limbs, deviation of the head to the right, nystagmus, blunted 
sensibility, diminution of vision and of olfaction, dilated 
pupils and pupillary stasis. The cerebral temperature taken 
for seven days preceding death, gave as mean, the follow- 
ing figures: 

Frontal median region 35.83 

Frontal left " ^34.83 

Parietal " " _ 34.66 

Occipital median " 35.27 

Frontal right " 35.00 

Parietal " " .34.83 



♦The translation of the cases of Mills and Gray into the medical literature of Italy 
show a flattering appreciation of American experimental clinical work, for which the author 
cordially thanks his eminent Italian confreres In neurology. 



78 

Bert followed up these by exploring cranial tempera- 
ture areas corresponding to localities of brain, regarded as 
the seats of diverse functions and found some exaltations 
of temperature to follow intense psychomotor activity, but 1 
have not the precise focal results to give you of his subse- 
quent experiments. I think the range, however, did not 
exceed one degree. 

Since all tissue are heat producers or thermogenic dur- 
ing vital activity, the brain is no exception, notwithstand- 
ing its special thermogenic centers. The liver is probably 
the greatest heat producer, the blood from its haepatic vein 
being warmer than that of the portal vein going to it, and 
muscles in action are thermogenic. 

"The normal axillary temperature is about 37.5 C, that 
of the mouth a little higher and of the rectum slightly more 
elevated. The mean temperature of the blood is placed at 
39 C." (Wesley Mills.) 

The mean temperature of the body accessible to the 
thermometer varies not more than a degree and a half 
centigrade. The temperature of the haepatic vein (Wesley 
Mills Physiology) has been put down at 39.7 C, and it 
contains, as already said, the warmest blood of the body. 
The average normal temperature of the head through the 
cranium is 36.10. 

THE EFFECTS OF CEPHALIC ELECTRIZATION ON 
HEAD HEAT AND HEAD CONGESTION. 

It is more than thirty years since I began the practice 
of cephalic galvanization for epilepsy, cerebral hyperemia, 
hypera^mic headaches, cerebral hypothermia and other con- 
ditions associated with vaso-motor instability and arteriole 
irregularity in the brain's circulation apparatus. In support 
of the views 1 long ago held on this subject I published in 



79 

^the Alienist and Neurologist for January, 1880, M. Ch. 
Letournian's experimental contribution undertaken to deter- 
mine what is the effect upon the vessels of the brain, of a 
moderate electrization with the galvanic (continuous) cur- 
rent through integuments and the cranial wall as nearly as 
practicable in conforming to ordinary therapeutic applica- 
tions. He made bare in a mammiferous animal a portion 
of the cerebral membranes and proceeded with the follow- 
ing demonstrations, securing a most valuable and triumphant 
demonstration of the inestimable physiologico-therapeutic 
fact that galvanism of the meninges of the brain will con- 
tract the arterioles of the brain's enveloping membranes, 
and 1 can likewise assure you the same agency so applied 
from os frontes to nuchae, with thoroughly wet sponge 
electrodes, P. pole to neck, N. pole so as to reach the 
cerebral vaso-motor centers of other parts of the brain by 
the current's course, will favorably impress brain congestion 
and arteriole irregularity and help in the cure of curable 
cases of epilepsy, etc., of which 1 shall speak in detail later. 
"Doctor Laborde assisted him in the experiment on a 
kitten a month old, in which the cranial wall was still very 
thin and was quite easy to cut, a considerable portion of 
cranium had been cut on the left side. The dura mater 
being so exposed it was very easy to see with the naked 
eye, and still better with a magnifying glass, the arterial 
and venous branches which ramify upon the surface. They 
proceeded then to the electrization, making use of the small 
portable pile for continuous current, of MM. Onimus and 
Brown. This pile contains eighteen elements and they took 
care by the aid of a galvanometer introduced into the cir- 
cuit to assure themselves that the passage of the current 
was effected regularly. During all the duration of the 
experiment, the positive pole was placed behind the right 



80 

cending ramus of the inferior maxilla and the negative 
pole upon the anterior cranial region above the eyes. 

Ten or fifteen seconds after the closing of the circuit, 
the fine arterial branchings of the dura mater became less 
and less visible, and a little later, the venous branches them- 
selves became pale. At each interruption of the current 
the anemia increased for an instant, then the vessels 
resumed, little by little, a little larger caliber. 

The experiment, repeated a number of times, gave 
always the same results, determined successively by Doc- 
tors Duval, Laborde, Conderceau and themselves. The 
dura mater of the right side having been denuded in its 
turn, the experiment was repeated, which on this side 
again gave the same results. They pursued the experi- 
ment, cutting on the left side a portion of the dura mater. 
The pia mater being thus exposed, and its vascular 
branches, arterial and venous, being very visible upon the 
gray ground of the cerebral substance, the same observa- 
tions were made upon it. There also, we could obtain at 
will, contraction of the vessels. 

The experiments just related, they go on to state, added to 
fads cited in the commencement of this paper, put it beyond 
doubt thai it is possible, even easy, to produce in man a tem- 
porary anemia of the brain, by means of suitable electrisation; 
but the therapeutical bearing of this fact should not escape the 
physician. For this temporary anemia can, without the least 
inconvenience, be renewed a great number of times daily, if one 
wishes; and our personal experience permits us to affirm that, 
with a little persistence one may triumph so over various con- 
gestive states of the brain, manifesting themselves either by the 
simple depression of the intellectual faculties or by psychical 
disorders of varied nature. 

In support of the preceding statement they cite a typ- 



81 

ical case of chronic congestion of the brain, which has 
yielded to electrization repeated persistently, but which 
-we omit. 

The abbe C, aged fifty-five years, is a corpulent, full- 
blooded person, with a highly colored countenance; he 
applied to us in despair because he suffered several times 
si week from persistent vertigo, during the duration of 
-which he could not take a step without support, and from 
'which he was relieved only by absolute repose. M*. C. 
belonged to a religious community whose principal object 
is teaching, but he was obliged to renounce, little by little, 
.all work. It had come to pass, he said, that he could 
scarcely recite his breviary and say mass. After various 
"treatment, there was made to him, at the end of five 
months, an application of fifteen leeches, with so little effect 
-that the next day he had a severe cerebral congestion, with 
loss of consciousness and instantaneous fall. This serious 
accident occurred several times afterwards, and was ordinar- 
ily accompanied by violent vomiting. 

To modify this inveterate organic state and restore a 
proper tonic contraction to vessels habitually dilated, a 
treatment of long duration was necessary. During five 
months they electrized the patient three times a week, 
placing the positive pole of a pile with continuous current 
at the level of the first cervical vertebra, the negative pole 
at the level of the superior ganglion of one of the cervical 
sympathetic nerves. The number of elements employed 
varied from fifteen to twenty, and they took care to inter- 
rupt the current every fifteen seconds; for experience shows 
that vascular contraction is produced especially at the open- 
ing and closing of the current. 

Each seance effected an immediate amelioration and 
longer and longer. Soon the patient was able to resume 



82 

his occupation, and to work, at first, one hour, then two 
hours, then four and five hours per day. At the same time 
the attacks of vertigo became more and more rare and brief. 
At the end of five months, the patient ceased a treatment 
which was no longer necessary; and for several months the 
alleviation has continued.* 

This fact is so eloquent, they say, that it appears to them 
useless to accompany it with comments, and it will surely 
suggest to practicing physicians, therapeutic applications 
numerous and various." 



*Ga?ctU HekJom.. 3 Oct.. 1879. 



CHAPTER VIII. 
the temperature sense, Ere, and its alterations in diagnosis. 

THE MUSCULAR SENSE AND SENSE OF WEIGHT. 



The condition of the temperature sense is best deter- 
mined, after ascertaining the real thermal condition of the 
patient by means of the ordinary clinical thermometer, by 
^applying to the patient's skin alternately hot and cold and 
^varm waterdiscs or bottles or sponges of water, hot, cold 
snd warm, and interrogating him as to what degree of heat 
sensation he feels at each application. 

If you have reason to suspect the patient or wish to 

exclude the possibility of malingering, apply the temperature 

"tests unexpectedly and out of the range of the patient's 

-vision at the time. He should also be otherwise managed 

about as in making an ordinary restheseometric 

examination with an restheseometer, i. e. % suggestion of 

what tests you are about to use should be avoided. He 

should neither see the water heated nor cooled, boiled 

nor frozen. 

Besides BecquerePs discs and Lombard's thermo- electrical 
differential calorimeter they use in some of the Paris hospitals 
an instrument called Blocq's thermoaesthesiometer, but an 
ordinary bath or water thermometer perforating a rubber 
stopper or disc of aluminum to keep it stationary and 
upright, and immersed in a test tube or bottle partly filled 
with water, capped to prevent the water spilling out and 

[83] 



84 

heated or cooled to suit the purpose of your examination 
will answer quite well. 1 show you the different devices 
and you may make your own choice. 1 think mine, like 
my Texas friend Beall's green straw catheter, is more 
readily devised for the emergency of country practice and 
less expensive, besides teaching a lesson in self-reliance in 
practice. 

Beall used to make capital fly blisters of potato bugs, 
mashed and rolled with lard and a rolling pin, and they draw 
well. If you should be called to a patient with high brain 
heat, too much blood in the head, a slow, full pulse, stupor 
and delirium or other apoplectic threatenings, put a sinapism 
or fly blister to the back of the neck to impress the vaso- 
motors and through them contract the cerebral arterioles. 
If neither mustard nor cantharides, or Spanish cantharadin 
ointment are at hand and the potato bugs are on the vine 
gather them in and imitate Beall's example. He made his 
mark on the profession as a successful man of expedients 
in practice like Tom Flornouy, one of Joe McDowell's 
patients on whom McDowell first tried Samuel Thompson's 
number six for dysenteric inflammation on the Hahnemann- 
ian principle of similia similibus curantur, sending his 
patient out the window and down the streets of Chillicothe 
without his trousers, clasping his nates with both hands and 
crying fire! Flornouy put out the fire in his rectal rear on the 
more rational principle of plenty of cold water and contraria 
contrariis curantur morbi. 

There are principles of practice on which I would 
always have you mens conscia recti, which liberally and 
latitudinously translated means, always be right on the 
management of the rectum, liver and other organs, if you 
would make a success in neurological practice. Do not 
treat but one spot and that spot the nervous system only. 



85 

And this reminds me of an apropos clinical illustration, 
vii: a profound melancholia may be brought on; (that is, 
where a previous psychopathic constitutional proclivity 
exists which in neurological parlance we call a neuropathic 
diathesis,) through aggravated drain and irritation of the 
neuraxis centers, by a blind fistula in ano and cured by its 
prompt and efficient surgical relief. Such a case impressed 
me early in my professional career when I was a young 
military hospital surgeon. Examining the patient as 1, even 
that early, was accustomed to do, all over, 1 found the 
fistula and with my bistuary made an open sore of it and 
healed it from the bottom. Simultaneously with his rectal 
recovery, the rest and recuperation of his nerve centers 
came about clear up the cerebro-spinal axis to his cerebrum 
and lo! the melancholia was gone. And thus it is in prac- 
tice we sometimes make both ends meet our purpose. In 
such a case as this the proctologists are not to be despised. 
They are useful workers at the other end of the neurolog- 
ical line and sometimes they may triumphantly exclaim, 
speaking of their special work, finis coronat opus! For 
man is a "vast chain of being," as 1 have said, when we 
consider the intimate relations of the grouping and chaining 
together of the wonderful neurones and neurone projection 
system that make up so much of his wondrous organism. 

BAROMETERNATUR OR BAROMETER NATURE. 

Let me now call your attention to a nervous condition 
•especially peculiar to some neurotics in which a not easily 
describable heaviness of feeling and malaise possesses the 
patient under low pressure barometric states. It is not 
Katzenjammer but Birometernatur, as our German friends 
would say. It is an indescribable feeling appearing with 
atmospheric changes. The uric acid and the gouty neuro- 



86 

path often show it in connection with slight joint tinges 
and muscular pains and chronic malarial toxhaemics who have 
long ago ceased to have periodic malarial attacks, and 
chronic neurasthenics show it. Study this and see what 
you can make of it in after years of your medical obser- 
vations. 

An irreverent patient will come into your office and 
say, "this weather makes me feel like h — I;" another will 
more gently say, "1 feel mighty badly when these changes 
come," and yet neither can tell why. They expect you to 
know and tell them why. You will say learnedly, it is 
barometric or Barometernatur impression and their peculiar 
nervous susceptibility, /fyw, meaning pressure, you know, 
and n*Tpov t measure. You give them an insulated seance in the 
static chair, letting them smell the generated ozone of the 
battery and give such other prescription as tongue, pulse, 
etc., may indicate, say encouragingly, it will help them and tell 
them to come again if they do not feel lighter and better 
in a day or two. A good static treatment and a laxative 
relieve this feeling often. But it is wise to see the 
patient more than once, especially after the weather shall 
have changed and if such a feeling persists then examine 
him thoroughly by physical blood test and urinary explora- 
tion. He may have the beginnings of graver nervous 
trouble. It is well to examine all patients thoroughly even 
when they complain of comparatively slight and indefinite 
nervous symptoms, bearing in mind the sartorial motto, "a 
stitch in time saves nine," which Hippocrates might have 
made into a good medical aphorism but I do not recall that 
he did — though there is a similar one in the saying that 
"an ounce of prevention is worth a pound of cure." And 
my friend Marcy says, "an ounce of taffy is worth a pound 
of epitaphy." 




S 1 



Si 



When persons born and acclimated to our atmosphere 
show this Barometernatur their condition should be inquired 
into. They may need neurological or other medical at- 
tention. It is well, in all such cases, to establish the 
habit among your clientele of seeking from expert sources 
to know the significance of minor and incipient ailments 
-that may be beyond their sight. The physician nowadays 
may see things by revelation of slide and lens, not visible 
to ordinary observation, as the astronomer sees the heavens. 
There are things beneath the over-arching dome of man's 
brain, down among the neurones of the cortex, basal ganglia, 
motor and sensory tracts, as difficult to see by common 
sight, as some distant planets and stars of lesser magnitude 
^re to discern by other than expert astronomical vision. 

THE MUSCULAR SENSE AND SENSE OF WEIGHT. 

The exact consciousness of a man's muscular power is 
different in different individuals. If you know that a man 
has been accurate in the estimating of weights, you may 
gain some knowledge of his deterioration in this regard if 
any exists, by testing him with different weights. Also after 
ascertaining if he is right or left handed or ambidextrous 
and comparing both his weight holding and his weight 
estimating capacity. Through the muscular sense which is 
really a nerve ending sense the mind is informed as to the 
state of the muscular tonus, power and capacity of endur- 
ance. Some men are better endowed in this particular than 
women and at some times than at others in their lives. 
Elasticity of step, vigor of muscular movement, erect or 
stooping posture and steadiness of gait and standing are 
connected with it, even when there is neither muscular 
atrophy, pseudo-hypertrophy nor sclerosis. Absence of 
muscular tonus, accurate consciousness of exact muscular 



88 

strength and power associated with the neurotrophia and the 
myatrophia and myasthenia of neurasthenia and are to be 
estimated in diagnosis. The healthy man has an approxi- 
mative normal conception of his muscular power, a sense of 
muscular tonus that the neurasthenic, for instance, has not. 
The neurasthenic is uncertain in this regard, as he is timid 
and irresolute mentally. He feels constantly tired when in 
mental and muscular repose and may tell you he was born 
tired. At any rate, he has that constant "tired feeling" the 
advertising newspaper quacks are always on the lookout 
for, and which means nerve tone exhaustion, but which the 
quacks usually tell him mean much more. 

A healthy man has a normal conception of where his 
muscles are and the different parts of his body and can 
find and touch these parts in the dark or blindfolded. He 
knows where his feet, toes, hands, fingers, nose, mouth, 
ears, etc., are and can touch them readily with his eyes 
shut. Flex one of his limbs and he can tell you without 
the use of his eyes, what you have done. When the 
muscular sense is defective this can either not be known to 
the person or it is imperfectly appreciated according to the 
degree of impairment. 

In locomotor ataxia for instance this defect is so grave 
that the ground does not feel natural to the victim of this 
disease when walking and he cannot find his nose tip, 
approximate his finger tips or touch his ear lobes with accu- 
racy when his eyes are shut. This is a blending of impaired 
muscular sense and incoordination. The sensory nervous 
system is impaired in locomotor ataxia and the nervous mech- 
anism of the muscular system misinforms the brain when 
the muscular sense, as it has been termed, is impaired. 

The tactile sense or the general sensation sense, is 
different from the muscular sense, for they may be inde- 



89 



pendently impaired. It resides chiefly in the finger tips or 
on the skin and is important in diagnosis, as we shall dis- 
cover later. The tactile sense is the sense of touch and is 
measured by touching. The chief instruments for it are 
the sesthesiometer and the thermoaesthesiometer, the former 
already shown you and the latter, thermoa»sthesiometer, 1 
show you now. 

The muscular sense is not tested by the dynamometer 
which I now show you but the dynamic power or muscular 
strength is. (See chapter on Instruments of Precision for 
further illustrations.) 

Hammond in this country first called the attention of 
neurologists to the thermo-electric 
calorimeter, an instrument used by Dr. 
Lombard for determining differences of 
temperature as my thermoasthesio- 
meter is. 

Ranney modified Lombard's instru- 
ment and described his modification 
in his very descriptive treatise on 
neurology. 

The construction of this device is 
so simple that its appearance explains 
itself. It is simply a graded ther- 
mometer in a jar in which water at 
different temperatures is poured and 
the jar or test tube thus filled is ap- 
***** JIIM.CU****** plied to the skin. 



a* 



? 




CHAPTER IX. 

EXTRA-NEURAL OR ADNEURAL NERVOUS DISEASE. 

SYSTEMIC STATES LEADING TO, PROCEEDING FROM AND BLENDING 
WITH NERVOUS DISEASE; MALARIA, ERYTHROCYTES, 
THERMASIA, THERMESTHESIA; THEIR EFFECTS 
ON THE NEURONES, ETC. 

The object of this course of lectures is not s6 much 
to make you great experts in neurology, (the time is too 
short and life is too short for that and for the general 
practice of medicine at the same time), but to teach you to 
clearly detect and intelligently appreciate nervous states in 
disease and the relation of other diseases to nervous dis- 
ease; to make you discriminating in searching out causes 
and conditions of nervous disease and all the factors of a 
nerve disease problem. To be a good neurologist, even for 
the needs of a general practice, you should be a good all 
around physician and therefore a good diagnostician,for you 
must differentiate in diagnosis, neural from other diseases 
and be able to treat the entire patient or to know and 
advise how, where and when and by whom you should be 
assisted in your treatment of certain diseases. In nearly 
all disease the nervous system is more or less in evidence. 
In some morbid states, though, the nervous system is so 
prominently affected, though chiefly in a secondary manner, 
so markedly thus involved, as to be designated as nervous 
disease. For instance, locomotor ataxia and general paral- 

[90] 



91 

ysis of the insane are supposed to result from syphilis as 
the chief predisposing factor, to which some special brain or 
spinal cord strain, like excessive venery and prolonged stress 
on the cord or brain, or other damage has been super- 
added, though Drs. Bruce and Ford Robertson* have lately 
contended that general paralysis is caused by gastrointes- 
tinal auto-intoxication, resulting from excessive growth of 
micro-organisms that normally inhabit the alimentary tract. 
But in these diseases, changes have taken place in the nerve 
centers before the classical nervous disease appears. In the 
first, the posterior columns and root zones of the spinal cord 
have undergone an indurative tissue change, a proliferation of 
tissue elements, called sclerosis. In the second the super- 
ficial layers of the grey cortex of the brain have become 
the seat of a subacute inflammatory action with antecedent 
and resultant vascular and brain substance change. The pial 
arteries have become inflamed and finally the connective tis- 
sue generally and the psychic neurones and psychomotor neu- 
rones are more or less damaged or destroyed. In the begin- 
ning, however, you have adneural or extra- neural exudates 
and pressure excitation, adventitia or adventitious deposits 
as they are called and their nervous results. This is the 
pre-paretic stage of paresis as 1 have elsewhere pointed out. 
But there are other diseases of the nervous system due 
to syphilis in which the nervous system is not implicated in 
the beginning at least; that is to say, that special part of 
the nervous system involved in the causing of the symptoms 
grouped together as cerebral or other forms of syphilis of the 
nervous system, and yet the symptoms are all nervous, such 
as syphilitic arteritis of the brain and those forms of cere- 
bral or spinal cord disease which result from the adventitious 
deposits of syphilis, the exudation of gummata over vital areas 



•See EJinburg Medical Journal for December. 1901 . 



92 

of the nervous centers and sometimes involving the peripheral 
nerves, as in syphilitic neuritis. There is also alcoholic poly- 
neuritis and the lancinating pains of chronic meconism or 
opium toxhremia revealed in chronic opium habitues when the 
repeated doses which cover up the poison and pain are sud- 
denly withdrawn for any cause; those terrible muscular pains 
which come on synchronously with the exhausting colliquative 
diarrhoea often, after the accustomed drug is sensibly and 
suddenly reduced to more than one-half the accustomed daily- 
quantity and which cause the humane physician to prefer 
the gradual to the abrupt withdrawal of this terrible drug from 
its unfortunate victims.even though anodynes of the coal tar 
derivative class may now be substituted for the pains of 
sudden drug withdrawal. 1 have termed this implication of the 
nervous system in disease caused by conditions developed 
outside of its intimate structure and oppressing, by pressure 
and compromising nervous functions, extra-neural disease. 
My friend, Professor Gowers, whose splendid work 1 have 
so often commended to you for reading during your leisure 
hours, calls this condition adneural disease. Cerebral apoplexy, 
cerebral embolism, thrombosis, meningeal disease, etc., are 
of this nature, though sooner or later the brain substance 
becomes involved, sometimes immediately in some or all of 
these conditions, except fever and meningitis, and often these 
soon implicate the brain, though there may be delirium 
before the brain is injured either by pressure exudate or 
destruction of substance. The disturbance of brain then 
comes from the fever poisoned and altered circulation. 

This also is extra -neural. But the symptoms are nerv- 
ous because the brain is disturbed and it is a great nerve 
center— the greatest nerve center or aggregation of nerve 
centers of the body; the highest nerve center, composed 
of the psychic and psycho- motor and sensory neurones. 



93 

The recent cranial traumatism that depresses the skull 
and causes a convulsion which disappears on trephining or 
chiseling and elevating the depressed bone thereby relieving 
the oppressed brain, is of this nature. But the resulting struc- 
tural change in the brain beneath is intra-neural disease and 
if the depression last long the "epileptic change" may set in 
and developed epilepsy or other disease in the brain and the 
condition is no longer adneural or extra- neural but intra- 
neural also, because it and the disease cannot be removed 
by an operation. When the first fits of alcoholic epilepsy 
come on, their cause is extra -neural, in the sense that we 
have arteriole dilation or vessel spasm and blood pressure; 
but a nervous phenomenon, that of vaso- motor paralysis and 
arteriole dilatation has preceded, while the hereditary epileptics, 
descended from excessively alcoholized parents, are not ad- 
neural epileptics. Their epilepsia is called idiopathic because 
not due to other and extra-neural causes. The convulsions 
of childhood are often extra- neural, from the painful irritation 
of dentition, or from gastro-intestinal or meningeal irritation 
or irritation elsewhere. Cerebral traumatism may be alto- 
gether extra- neural at first simply from skull depression. 

The metastasis of a facial erysipelas to the brain is 
extra- neural in the beginning, that is, its specific toxicity is, 
but it causes delirium and fatal brain disease as well as 
the vaso-motor nervous disturbance which results from and 
accompanies the poison (streptococcus erysipelas). The 
vaso-motor system as well as the streptococcus is concerned 
in the characteristic sharply circumscribed cutaneous ere- 
thema which goes along with the specific inflammation of 
the cutaneous and areolar tissue, making this specific disease 
whose tendency to metastatic change to the brain, you are 
cautioned in your text- books on practice to guard against, 
by administering large doses of muriated tincture of iron, 



94 

etc. Erysipelas is as prone to "strike in" on the brain a^- 
parotitis or mumps is to go to the testicles and both are* 
delicate spots to be touched by specific inflammation. The- 
gonococci, too, may migrate from the urethra to the brairm 
as well as to the prostate, testicles and joints* and that 
fearful looking swelling, gonorrheal orchitis is not nearly sc^ 
formidable as that condition of the brain or other, nerve- 
center following the invasion of gonnocci there. Yoa 
may have a brain or other nerve center disease on your 
hands to treat from this cause, as grave as if it came from 
the poison of syphilis. 

Cerebro-spinal-meningitis and diphtheria and their 
inflammatory exudates are extra- neural, but they give you 
serious nervous diseases to treat, as grave as paralysis. 
The cerebro-spinal fever and post-diphtheritic paralyses 
are more hopeful in prognosis than some other forms, because 
their cause is extra-neural, something added to the nervous 
system and not always grave, irreparable, nerve tissue 
damage as in that true intra- neural disease — posterior 
spinal sclerosis, for example. These poisons develop 
abscesses in the brain and other nerve centers as 
well as the joints and kill often. Gonorrhoea, gout or rheum- 
atism will interest you as much in nervous as in other 
diseases. 1 can now speak much more hopefully, however, in 
regard to staphyloccocus or gonococci infection of the brain 
than my friend, Sir Dyce Duckworth. 1 have seen, in my own 
practice, many of these forms of paralysis make complete 
recoveries. I once had a young man under treatment for 
paralysis of the upper and lower extremities, also insane and 



♦See Rheumatism and its Counterfeits, a clinical lecture at St. Bartholomew's. Nov. 
29th. 1901. by Sir Dyce Duckworth, M. D . L.L. D. of London. England, reported for the 
Philadtlphia MrJical Journal January 2. 1901. Whatever this author or lecturer say t or 
writes on the subjects of gout or rheumatism will be profitable for your consideration In the 
management of those conditions so often connected with nervous disorders. 



95 

deaf and blind, who recovered everything but his sight in 
six months from the onset of his post cerebro-spinal-men- 
ingeal malady. He became robust and grew to mature 
manhood In the blind asylum here, where he learned one of 
the trades of that benevolent institution. Autotoxhaemia 
or self blood poisoning is a fruitful source, as you are ready 
to surmise from what I have already said of extra- neural 
or adneural disease. Sydenham and Scudamore, who long 
ago were authorities on gout, pointed this out and even 
Hippocrates and Shakespeare. The great English dram- 
atist made many other sagacious medical observations. 
"The Scripture saith the blood is the life" as physiology 
teaches, and that immortalized name in the annals of med- 
ical literary fiction, Sangrado, who purged and bled and 
filled his patients with water, (not normal salt water solu- 
tions now so valuable in states of depression hypodermic- 
ally) regarded all disease as extra -neural. He believed 
in the value of a flush in physic, like my friend Dr. 
Love who addressed you the other day, and a flush is 
a good thing if you know how to play it in the game of 
therapeutics where the integrity and life of nerve centers 
are at stake.* 

These adneural affections promise more hope of recov- 
ery than many other forms. When you come across them 
treat the patient constitutionally all over, remembering in 



•Since these lectures were delivered my friend, Dr. George F. Butler of Alma, Michi- 
gan, in a recent able contribution in that indispensable medical periodical, the Journal of the 
American Medical AsuxUtion, which you all must have when in practice, opportunely quotes 
from Sydenham on this very subject and makes some further forceful and pertinent points 
which 1 commend to your reading. Sydenham pointed out that suppressed gout (that is, gout 
without joint expression.) exercised marked influence on the constitution. The body, he 
remarks. "Is not the only sufferer and the dependent condition of the patient is not his worst 
misfortune. The mind suffers with the body, and which suffers most is hard to say. So much 
do mind and reason lose energy as energy is lost by the body. so susceptible and vascillating 
Is the temper, such a trouble Is the patient to others as well as himself, that a fit of gout is a 
fit of bad temper. To fear, anxiety and ether pass'ons. the gouty patient is a continual 
victim; whilst as the disease departs, the mind regains tranquility." He also, as Butler 
notes, "pointed out that tout affected the throat, heart and lungs as In asthma." 



96 

your therapeutics the causes that have left the neural 
sequences and let your motto be "nil desperandum." 

These antecedent systemic diseases which result in 
serious sequelae *of neural development and grave systemic 
nervous diseases show the importance of an all around 
extensive knowledge of the operations of disease and the 
necessity of knowing all, in order to work wisely and well 
on a part, in the practice of medicine. The nervous system 
in some of the divisions is involved in nearly all altered 
physiology. Conditions such as we are considering and 
conditions such as 1 have hinted at and other morbid 
phenomena which 1 might mention, did time permit, and 
some of which are yet so important that 1 shall have to 
refer to them, that led the great Dr. Cullen to say that 
from all he could see of the movements of disease in the 
human organism they might all, in a manner, be called 
nervous, or words to that effect. Extra- neural nervous 
diseases also have their origin in nerve center impli- 
cation elsewhere than at the place of disease manifestation 
in the system, as in the changes due to disease damage 
and implication of vaso- motor and heat centers in the brain 
and those ganglionic changes that cause disease, changes 
and disordered action in the viscera, fourth ventricle 
changes in glycosuria, and the vagus center changes there 
causing cardiac, arythmia, tachycardia, etc. 

One other subject is so important in the understanding 
and treatment of nervous diseases of the central Mississippi 
valley countries of the United States, the west, northwest 
and south, whose waters wash their way to the Gulf of 
Mexico through the great Father of Waters, that I must touch 
it briefly before I close. That subject is malaria in connection 
with nervous disease. This too gives us many extra- neural 
nervous conditions to consider. 



97 
PLASMODIUM MALARIA, ERYTHROCYTES,THERMASIA, ETC. 

The malarial Plasmodium which attacks the erythrocytes 
or fully developed red corpuscles of the blood, as distin- 
guished from the erythroblasts or rudimentary or nucleated 
red corpuscles will claim your attention many a time and 
oft in practice. It is interesting to note the selective 
affinity of this Plasmodium, like an endowed intelligence, for 
the full-grown red corpuscle over the erythroblast, and it 
will interest you to watch carefully the wicked work of the 
malarial parasites, developing the remittent and different forms 
of intermittent fever, as you may see them displayed where 
most of you live, for these varieties, the remittent, the quo- 
tidian, tertian and quartan intermittents, depend for their 
manifestation on the manner in which the nervous system 
responds to the presence of malarial germs in the blood 
and to the form of this pernicious parasite of Laravan. 
You will see in those excellent plates of C. E. Simon which 
Duane has put in that useful little dictionary whose defini- 
tions I like so well, though 1 do not always approve his 
pronunciations, very impressive illustrations of the perni- 
cious work of this poisonous parasite group, whose mischiev- 
ous and destructive work on the nervous system, central 
and peripheral, has not all been as yet recorded. Look out 
for it in your practice. In spring and autumn the rains 
fill the porous earth and the malaria comes out to cause 
the aestivo-autumnal fevers. 

It is your enemy and the enemy of your patient, where 
or near where many of you live. It is the old marsh miasm 
of Elliotson, Watson and the other older writers, now trans- 
lated into the "bugs of the bogs," as they call them in 
Texas. Its or rather their, home is in the marshes, bayous, 
the watery wastes, flats and sloughs, or where the soil is wet 
and porous and often broken and where the culex mosquito 



98 

makes his haunt and vegetable decay goes on, and where 
you may feel at night time the sting, if you do not hear the 
merry murderous song of this festive anophile. It does not 
abide altogether in the marshes but migrates to the blood 
of man. Mosquitoes carry it. Perhaps other insects do, the 
gnat and other culices, and it is wafted on the winds of 
eventide and the night time after the sun is set. It gets 
into man's body through air and water and is the mal air 
constituent, carried by the malarial water and whence the 
term malaria. It gets into the body and sporulates there, 
breaking down the red blood corpuscles; it destroys the eryth- 
rocytes, as the learned bacteriologists tell us, and when 
the red blood corpuscles are being destroyed, the beginning 
of the end has begun with man. Disintegrated blood 
corpuscles cause anaemia, simple at first and finally per- 
nicious, causing symptoms resembling typhoid, causing vital 
depression in other forms, anaemic neurasthenia, neuralgia, 
neuritis, vaso- motor paralyses and its sequent paralysis, the 
paralyses of malarial congestion and toxhasmia. The chill 
and fever and reactionary sweating, congested and disordered 
spleen, liver, kidney, bowels; the jaundice, hematemesis, 
hematuria, etc., and sometimes albuminuria of profound ma- 
larial toxhaemia, are not the only mischief malaria makes 
with man, as you can see, for from this poisonous agent may 
come delirium and coma, which are nerve center 5ymptoms 
like the chill, etc. It may, in other ways, attack the brain, 
spinal cord and peripheral nerve centers (the ganglionic) 
pigmenting them after sporulation, (though pigmentation is 
not always nervous disease), and marking man for destruc- 
tion in many ways, through nervous disease not yet, by 
common professional consent, attributed to this potent 
poison. So that unless you come skillfully to the rescue 
with timely and adequate doses of quinine and other anti- 



malarial and blood reconstructives that kill these parasites, 
clestroy these microscopic "bugs of the bogs," rebuild the 
blood and save and restore the damaged nerve centers, and 
prophylactics against malaria, your patients after a time 
may die of the consequences of malarial poisoning. It has 
l^een the practice on the plantations of the south for more 
Lilian half a century to use large doses of quinine and other 
salts of cinchona, dogwood bark, salicin from the willow, etc., 
s*s preventive of malarial disease, though Kock speaks lately 
<^ n the subject as though it were yet new. The old doctors 
<z*f the marshes and bayous of the west and south can tell 
'V^ou well the old, old story of malaria arid how they warred 
^a. gainst it with quinine, arsenic and other prophylaxis. You 
■must kill the parasitic enemy, cast out the devil of destruc- 
tion and repair the damage done to the organism, as well as 
"to the blood, in order to save your patient's nervous system, 
i involved in the onslaught of the parasitic invader. Neurotic 
^^nd haematic reconstruction will help to save the imperiled 
*~*erve centers from damage. So will bromide of ammonium, 
J vidiciously used and the cinchona alkaloids and salicin, 
^^ncalyptus, dogwood bark, etc., liberally employed, and 
*^*iercurials judiciously given, will drive out and destroy the 
^^nemy. You must give attention to general medicine and 
therapeutics in order to make a good neurologist, as well as to 
general pathology and diagnosis. 

Your study of the malarial Plasmodia in connection 
^ith their influence on the nervous system will give these 
parasites of quartan and of aestivo-autumnal fever an addi- 
tional interest and you will pay more attention to the chair 
of clinical medicine and pathology after these hints as to 
the neuropathic potentiality of the Plasmodium malaria 
given you. The culex mosquito and perhaps the culex 
pipens will interest you. For it has been found that there 



100 

is a female in the case and that the female culex mosquito 
here, as other females elsewhere, is capable of doing much 
damage to mankind. 

While considering extra-neural affections it is well to 
note in this connection, those hyperthermal or hyperthermo- 
haemic states and hypo or athermo or athermohsemic (hyper 
meaning + while 0*pm signifies heat wherever you may come 
across them in your reading), neural effects such as sunstroke 
and brain inflammations from external violence and certain 
febrile diseases on the plus side and the rigors and the chills 
on the minus side, which sometimes precede poliomyelitis ante- 
rior, as they do pneumonia and as they may follow the hypo- 
thermia of the febrile crises in typhoid fever. These affect the 
nerve centers as well as the blood and cause phenomena that 
are called nervous symptoms. 

Thermasia* {OipiuLcna, heat) the opposite of thermaes- 
thesia, the latter being a paralysis of heat perception, are 
also to be studied by you in the understanding and mastery 
of nervous disease. 

fig. 45. 



;1 




# * 5 

i 



Cut showing relation of blood vessels to groups of neurones and how 
abnormal vascular conditions may develop morbid states of nerve centers. 
The cut snows normal conditions. 



FIG. 46 



N^lZt Qmxi ^uL-nPu Mamms ahd Local 




/. AX V '8 CYUNDERGRAMUtflAMD SWOLLEN. Z*3 IIFBRiS 
OFWfMAIATMJB$0RB£JAA'D SHEATH EMPTY AMO 

IlLOSTRATHW A/VD ZJESCRtPTW AtWr/fD rfiOAl 
//AY£#. S,/lfo*/itAL wave; 



FIG. 47. 




FIG. 48. 
^W Ufcut^ Ufirveus fJiaeoae ©^ ymm. 







FlG. 49. 



Scarce 9<v'vU. ij'» b ©«K o «v '* CU^^ **t a, tv& 







l 




A, A f A, A, area of blood clot. The cord is here shown enclosed in itt 
dura! sheath. The projections are the spinal nerve sheaths, 

The smaller cut shows section of cord and spinal nerves with the dun 
drawn aside: 




CHAPTER X. 

EXTRA-NEURAL OR ADNEURAL NERVOUS DISEASE. 

EXTRA-NEURAL NERVOUS DISEASE; CHROMATIC AND ACHROMATIC NEU- 
RONES, CHROMATOLYSIS. THERMAL CHANGES IN THE NEURONES, 
BRAIN NEURONES AS HEAT CENTERS, ADNEURAL HEAT 
CHANGES OF NEURONES, MARINESCO AND LUGARO'S 
LAW OF MORBID NEURONE CHANGE, REFLEX 
PHENOMENA AND THE NEURONES. 

While traumatism to the brain and spinal cord and 
disease impression on the heat centers, cause directly induced 
nervous disease, the over -heating of the neurones and 
morbid changes in them may take place from superheating 
of the blood; i. e. f by hypoh&mothermia, as in sunstroke. 

Coup de solid may therefore be either an intra-neural 
or extra-neural nervous disease; according to the degree to 
which the neurones are involved and according to the man- 
ner in which it may be brought about, whether by the 
direct rays of a broiling sun overheating directly the neu- 
rones of the brain — or by the long continuance of high 
temperature, or it may be both, i. e. t brought about by 
excessive heat of blood and by direct overheating of the 
cerebral neurones combined and heat centers. 

When appreciably grave nervous disease results from 
the influence of extra- neural conditions, it is the achromatic 
portion of the neurone, the nucleus and motor segments of 
the cells, that appear to be mostly affected. The chromatic 

[101] 



102 

or chromophile or stain- receiving portions, if influenced, do 
not seem to make the subject so markedly interesting to 
the clinical neurologist. Here is a post- graduate theme for 
you. We shall however ask you no green room questions 
on this subject. 

Here as elsewhere some influences effect only appear- 
ances, others do the real thing. It is when the non-coloring 
element of the cell or neurone is involved that the chief 
real harm is done to the nerve centers. Why this is so 
cytology does not yet fully enlighten us. It is ready to 
learn from you as the oncoming cyto-scientists and cyto- 
savants of the profession. 

LUGARO'S AND MARINESCO'S LAW OF MORBID 
NEURONE CHANGE. 

Now gentlemen, most authorities say that the fibrillar 
portion of the achromatic substance subserves the function 
of conducting the nervous waves. Cajal, Lenhasseck, Rob- 
ertson, Nissl and some others consider that we are not war- 
ranted in attributing the performance of functions to the 
fibrils alone. The non-organized portion of the achromatic 
substance is believed by Marinesco to be the seat of intense 
chemical phenomena and of such importance for the nervous 
element as to be appropriately designated the trophoplasm, 
that is the plasma of nutrition. That this substance is the 
seat of important metabolic changes is amply confirmed by 
other observers, more especially by Guiseppi Levi from his 
study of the fuchsinophile granules. According to Van- 
gehuchten, Nissl, Lugaro, Lenhasseck, Cajal and many others 
the chromophile substance of the protoplasm is a material 
of reserve, destined to serve for the nutrition of the nervous 
element. Marinesco believes it serves to augment the 
difference of potential of the centrifugal nerve wave.* 

•Ford Robertson. Text-b<ok of Pathology and Nervous and Mental Diseases, pace 
222, edit.. 19(H). 



103 

The cell body contains, as you know, the nucleus and 
nucleolus and is the trophic center for the whole cell 
element as proved by ample experiment which cannot be 
entered upon today. Structural changes accompany modi- 
fication of function in the cell and vice versa, functional 
changes follow structural changes of the cells as 1 have 
already shown you. "When the energy of the cell is 
exhausted by prolonged or excessive activity the cell body 
and the nucleus are distinctly diminished in volume, the 
chromophile substance of the cell plasm or cytoplasm 
is small in amount and appears diffusedly granular. 
During normal activity the chromophile substance is uti- 
lized by the cell and slowly diminished in quantity," 
says Ford Robertson farther. This would seem to me 
to tend to establish the disintegration of the chromophile 
substance correlative with cell function and tend to show 
that it nevertheless has considerable to do with the poten- 
tiality of the cell fuchsinophile granules of Levi. The nucle- 
olus undergoes an increase in volume and the particles of 
chromophine adherent to it consequently tend to become 
more elongated. During rest the chromophile substance 
gradually accumulates again, the fuchsinophile granules 
diminish in numbers and the nucleolus assumes a smaller 
volume." 

Thus you see that whatever may be the cause or 
causes operating to develop nervous disease, whatever cause 
or gross change takes place in nerve centers or periphery 
through morbid alterations in blood supply or quality or in 
the environment of the nerve centers, or from traumatism or 
other external causes, it is the abnormal impression upon 
and the morbid response of the neurones, or glial connec- 
tions and their morbid expression, that gives us generally 
the phenomena of nervous diseases. Either the mesoglia or 



104 

the cytoplasm itself, i. e. t the cell plasm proper of the neu- 
rone either in its nucleus, nucleolus, neuraxone, dendrite, or 
gemmule, receives and responds in abnormal, crippled 
fashion to the morbid touch of its environment, whether 
this morbid touch be a germ, traumatism or a blood 
element altered in quantity, quality or toxically depraved, 
causing a change in the blood quality. 

Persistent malarial poisoning, chronic alcoholism, re- 
peated attacks of grip, the opium taking habit, habitual 
chloral, cocaine, cannabis indica and other narcotic drug habits, 
all of which are toxic to the neurones and in the beginning 
extra- neural, being impressions first made through the blood, 
should have much of your thought in practice. The medical 
practitioner should be on the lookout for these disturbances. 
Nerve tire, brain fag, the assaulting and weakening of the 
neurones are the beginnings of trouble and lead to grave con- 
sequences. We have here toxic neurones and nerve centers 
to deal with. As brain fag and nerve strain precede Bright's 
disease and dyspepsia ordinarily, and complicate other 
troubles, so do these extra or adneural states of the blood 
often precede pronounced nervous disease. The blood may 
be the life or death of the nerve centers and vice versa the 
life or death of nerve centers may be the life or death of 
the blood and of the organs the blood nourishes. The moral 
of this in medical practice is — take care of the neurones and 
of the blood as well as of the environment of your patients. 

The difference therefore between extra or adneural and 
intra-neural nervous disease is, that in the former the lesion 
of the nerve cell or some part of the neurone is secondary 
and functional to the extraneous influence imposed upon it, 
while the primary lesion has its beginning in the nerve cell 
or in its proliferations. Intra-neural may also follow extra- 
neural lesion because the extra- neural embarrassment of 



105 

the nerve or nerve center causes intra-neural change to 
sooner or later occur, as when nerve atrophy follows pres- 
sure or starvation of the nerve or neurone or nerve center 
group of neurones. There is an obvious difference too, in 
the gravity and permanence of the effect resulting from 
extia and intra-neural change, especially early in the dis- 
ease. The degenerations begin more tardily from extra- 
neural nervous disease and are often more readily removable, 
as in the adneural changes of syphilis, as 1 have already 
told you. Syphilitic nervous disease may be both extra 
and intra-neural. Marinesco* has recognized this fact. He 
says, "secondary degeneration of the nerve cell is uniform, 
beginning with disintegration of the chromatic substance in 
the neighborhood of the axis cylinder or neuraxone and 
extending to the rest of the neurone. The cell may repair, 
or it may atrophy and disappear. In primary degeneration 
the alterations are variable, grave and many." The achro- 
matic or non-color change substance is likely to become 
affected and this may make repair impossible and seal the 
fate of your patient. 

The pathology of the neurones, as 1 have already told 
you, will interest you in adneural as in other morbid nerve 
cell changes. They have been a never ceasing source of 
interest to me and the distinguished observer and author 
whom I have commended to you will make the subject 
entrancing to you in your vacation days. He quotes from 
Lugaro, who has summarized the effects of toxic agents on 
the nerve cells, much more than 1 have time to read you 
or you to listen, but I will give you enough to whet your 
appetite and in the summertime you may read the rest.t 

* G. Marinesco Les Polyneuritis en rapport avec les Theorle des Neurones. Bui. Med. 
1895. n 97. quoted by Ford Robertson. 

tVlde Ford Robertson p. 225. Lugaro. Recentl Progressl del' Anatomia de Systema 
Nervosa In Rapport alia Pslchologla et alia Pslchiatrla, Riv. de Patol. Nerv.e Mtnt., 1899 
11-12. 



106 

And those of you who have mastered the Italian lan- 
guage will find floods of light thrown on the fine anatomy, 
physiology and pathology of the nervous system by our 
wonderfully industrious and intelligent Italian confreies 
Levi, Marinesco, Lugaro, Chiozzi and others. 

These extra- neural influences affect the nerve centers 
through impression on the neurones, their neurites, den- 
drites, gemmulae, neuroglia or mesoglia. They affect them 
morphologically by pressure or chemically, as poisons do, or 
by more or less rapid transformation of the physiological 
function of the neurone into morbid action by anatomical 
change, and anatomical change in a nerve cell is usu- 
ally preceded by some sort of molecular change. Now 
for example the sequella? of typhoid fever, which may be 
either a delirium or typho-mania (psychic neurones), a 
paralysis (psychomotor neurones), or neuritis or neuralgia 
(peripheral neurones). 

There are some influences which affect one part of the 
cell without immediately at least affecting the other parts 
of it. For instance, temporarily compressing the abdominal 
aorta, as Lugaro has shown, will cause a color change 
(chromotolysis) in the chromophile or chromatic part of the 
neurone, which color change in the cell will persist for 
some time after the cause is withdrawn and the functional 
disturbance has ceased. Artificially induced hypothermia 
and melonitril poisoning will do the same. Other slow 
poisonings will do the same and similarly affect the chro- 
mophile elements of the neurone while fatal doses of 
chloroform or ether do not change the chromophile part of 
the cell, as Lugaro has shown. 

The chromatic part of the ceil seems to be concerned 
in the metabolisms and to be affected every time they are 
disturbed. Says Ford Robertson, "they play a very impor- 



107 

tani role in the functional metabolism of the nervous 
element, its alterations are a direct index of a nutritive 
alteration and that function will- be entirely suppressed 
when the structural dispositions of the achromatic (or non- 
coloring) part of the cell which seems more strictly related 
to nerve conduction, are altered morphologically or chemic- 
ally." Among the new problems therefore in the pathology 
of the neurone is Lugaro's* and Marinesco's law for them, 
now generally accepted as true by expert cytologists, to 
which 1 have already referred and which 1 repeat to impress 
you, and that is that changes in chromatic cytoplasm, or color 
preferring cell tissue or chromophile plasma, as it is differ- 
ently termed, represent the reaction of the neurone to the 
cell coloring influence that disturbs the neurone and color 
causing changes in the neurone. 

These chromatic changes in the neurone, and the same 
is true in neurology as in psychiatry, are reparable, while 
achromatic changes in the neurone are irreparable and degen- 
erative. Robertson quotes this law with approval in his 
excellent discussion of the morbid conditions of nerve 
cells and from whom I would like to read /'// extenso did 
time permit. Remember I have commended this splendid 
author for reference during youi leisure respite from the 
exacting demands of this course. It will prove a source of 
great enlightenment to you on the relation of cell pathology 
to mental diseases especially and also of cytopathology to 
neurology. Now this is the conclusion of the matter. 
Disease is impressed on the neurone, the neuroglia or 
mesoglia of nerve centers through either chemical or 
mechanical or morphological change. These neurones have 
chromatic and achromatic parts and are said to be chromo- 



*Nuovf data • ouovl problem! neila patologia delta cellula nervosi. Revista Ji Patologia 
Nervosiememtali. 1896. f 8. Vide ante from Robertson. 



108 

phile or achromophile, chromatic or achromatic; that is, to 
have either a color selection, love or color aversion or 
repulsion and love is an affinity in cytology, as well as in 
psychology, and chromophile cytoplasm or neurone changes 
are capable of regeneration and repair, while achromophile 
changes in cytoplasm are degenerate and irreparable and 
this reparability and non-reparability of the different parts 
of the neurone is Lugaro and Maranesco's law and by this 
law good diagnostic judges pronounce the verdict of life or 
death to nerve element and they declare prognoses of chron- 
icity or death to your patient in the grasp of a nervous 
affection. It is a valuable criterion for necroscopic conclu- 
sions in the cytopathology of neurology and psychology. 

That brilliant observer, Ford Robertson, to whom you note 
1 love to refer as I do, to the masterly Maudsley in matters 
physio-psychical, (vide p. 240) unconsciously touches upon the 
subject of extra- neural nervous disease without especially 
mentioning it in the following words under the head of 
morbid conditions of the nerve cells: "It is necessary to 
distinguish clearly between special diseases of the nerve 
cell, and mere types of morbid change that may be 
observed to affect it. Changes such as chromatolysis, vac- 
illation and the pigmentary degeneration, cannot be 
regarded as diseases of the nerve cell, but only as types of 
morbid alteration occurring in several forms of disease. At 
present the only definite diseases of the nerve cell that are 
known are primary degeneration (in which, however, future 
research will, without doubt, enable us to recognize various 
distinct forms and secondary degenerations)." 1 do not, 
however, concur with him in regard to vacuolation. 
Vacuolation may be a structural intra- neural as well as neu- 
roglial change. It is destruction of nerve cell or nerve ele- 
ment, or of the connecting neuroglial framework of the neu- 



109 

rone, and this is entitled to be regarded as structural nervous 
disease. If an egg basket is destroyed while it holds the eggs 
in place as the neuroglia hold the neurones in place, the eggs 
are apt to be displaced and damaged, if not destroyed. The 
neurones must similarly suffer in their glial framework under 
vacuolating change, as in that singular paralytic spinal nerv- 
ous disease, syringomyelia, whose pathology is revealed in 
gliosis or gliomatosis or abnormal proliferation or hyperplasia 
of gliomatous tissue and vacuolation, a disease whose path- 
ology I have sometimes curtly called in the clinics holes in 
the spinal marrow, as its Greek origins signify. Syrinx, <™/^y, 
a tube or canal and myelos, fivc\os t marrow, a chronic, painful, 
paresthetic, thermo-ancesthetic hollowing out disease of the 
spinal cord with trophic changes in skin, joint and bones, 
which we will discuss more fully later on. Likewise 
porencephalia. 

"Chromatolysis," is a color change or disintegration of 
ctiromophile cytoplasm, according to that eminent cytological 
authority. Marinesco, introduced by Robertson, who defines 
it as a disintegration of the chromatic particles of the pro- 
toplasm, breaking up the aggregations of the granules that 
form the Nissl-bodies and gradual disappearance of the indi- 
vidual granules, accompanied in transition stages by their 
diminished affinity for basic dyes. But it has been frequently 
used in a wider and more general sense, namely, to indicate 
the whole series of changes in the constituent elements of 
the cell, of which dissolution of the chromatic particles is 
merely the first that is recognizable. Its employment in this 
wider sense can only lead to confusion, and ought to be 
abandoned he says; but the clinicians and pathologists will 
continue to give it this wider meaning while the cyto-micro- 
scopists may restrict its pure cytological description. Van- 
gehuchten employs the term "chromolysis" as a synonym. 



110 

Chromatolysis or chromolysis has already been indicated. It 
accompanies primary and secondary degeneration in almost 
all their forms. Moreover it occurs as a physiological con- 
dition in fatigue of the nerve cell; as far as can be deter- 
mined by microscopical examination, the chromophile part 
of the cytoplasm is the most sensitive constituent of the 
nerve cell under abnormal nutritional conditions. (It is 
both primary and secondary in cell change). The exact 
mechanism of the production of chromatolysis in pathological 
states is little understood. Probably in certain instances 
there is especially an increased consumption of the chromo- 
phile substance, in others especially an arrest of its func- 
tion. " 

"Chromatolysis has been observed in the human sub- 
ject in a very large number of different morbid conditions. 
Indeed, it is now known that it occurs in some degree in a 
proportion of the nerve cells of almost every individual on 
the face of the earth dying a natural death. Even in noii- 
nervous diseases it is very commonly a very extensive and 
well marked accompaniment of morbid change in the cells 
of the cerebral cortex, spinal cord, etc. In such cases it is 
to be attributed to the action of toxic substances generated 
in the course of the particular disease, to pyrexia, terminal 
auto-intoxication or local vascular lesions. At the same 
time abundant evidence has now been accumulated of the 
special incidence of chromatolysis in various forms of nerv- 
ous disease. But in these cases it is generally accompanied 
by other morbid alterations in the cells which at once give 
to the pathological picture a much graver aspect." 

"Marihesco has applied the term 'achromatosis' to a 
change which consists especially in an extreme degree of 
chromatolysis — complete disappearance of the chromophile 
elements of the cytoplasm. In preparations stained with 



Ill 

* olychrome blue, the cytoplasm appears pale or absolutely 
olorless, resembling dull glass. He has observed this con- 
ition of achromatosis in the cells of the anterior root after 
vulsion of spinal nerves and in those of the cerebral 
ortex in diabetes insipidus, leprosy, pellagra, etc. It corre- 
sponds morphologically to the extreme degree of the lesion 
■bserved to attend experimental elevation of temperature." 
This discussion of chromatolysis is a little more complex 
^or advanced students of cytology than we have presented 
t and you will find much in the same line to interest you 
~ arther in Barker and other advanced cytologists, enough to 
entertain your leisure hours like a story and to reveal to 
Wou how much stranger than literary fiction are the truths 
iZDf advancing neurocytological science. 

The changes other than chromatolithic which take place 
in the neurone, consist of varicose hypertrophy of the axone 
mDi of the axis cylinder process as Golgi described it, the 
granular changes of Be van Lewis from which Ford Robert- 
son dissents, nucleal displacements, total or partial neurone 
obliteration or necrosis, homogeneous degeneration and 
atrophy and other changes not yet designated by name in 
cytology and other transformations of cells yet to be 
described. These will add to the marvels of your micro- 
scopes, as you may find time to look for them and search 
out the mysteries of microcosm for yourselves. 

Lugaro's more recent views also upon the pathological 
significance of lesions of the chromatic and achromatic parts 
of cells considered of so much interest and great practical 
importance that he quotes as follows, which 1 give you as 
still apropos to our subject and in proof, from higher author- 
ity, of what 1 have already said. 

"From the complex of the studies that have been made 
We may also form criteria of the reparability of the lesions. 



112 

We know that the lesions of the chromatic part of the 
neurone are the first to appear, in all cases in which the 
harmful action does not act suddenly and with such energy 
as to paralyze function; that they are in every case repar- 
able even when very grave, provided that other parts of 
the cell have not suffered serious damage. It is very 
doubtful if lesions of the achromatic parts can be repaired, 
more especially since they very often appear contempora- 
neously with lesions of the nucleus, the integrity of which is 
indispensable for the conservation of the cell. 

Of great importance is the question if functional dis- 
turbances ought to be considered as an expression, pure and 
simple of the lesions revealed by Nissl, that is to say, of 
those that concern the chromatic part of the cell. The 
results of experimental researches tell us clearly that an 
exact and constant relation there is not; that function can 
be disturbed without there being any apparent lesion of the 
chromatic part, which on the other hand may be altered, 
even gravely, without our being able to discover any evident 
functional disturbance. 

In acute poisonings, especially by substances which 
exhibit rapid diffusion and action, such as chloroform and 
ether, when there is really an imposing symptomatological 
picture, or when the toxic action has already determined 
death, one cannot recognize any apparent modifications in 
the chromatic parts of the nerve cells. Modifications are, 
on the other hand, very evident in sub-acute poisonings, 
even before functional disturbances have appeared. 

This shows without doubt that the functional activity 
of the cell can continue even when the chromatic part is 
injured, and that this part does not possess structural 
arrangements necessary for the fulfillment of its function, 
which depends therefore, upon chemical composition, and 



113 

not upon morphological disposition. If to this we add the 
fact that the chromatic part is rapidly affected every time 
that metabolism is disturbed, locally or generally, and that 
it diminishes in quantity in consequence of protracted func- 
tional activity, we can hardly doubt that the chromatic part 
plays a very important role in the functional metabolism of 
the nervous element, and that therefore its alterations are a 
direct index of nutritive alteration. In other words, they 
are not exactly proportional to the functional disturbance; 
within certain limits of structural alteration function can 
remain intact, and will not exhibit disturbance with certainty 
except in cases of grave alteration, when the nutritive 
alteration is also grave. On the other hand, function will 
be entirely suppressed when the structural dispositions of 
the achromatic part, which seem more strictly related to the 
nervous conduction, are altered, or when they are suddenly 
affected by energetic chemical action, and Ford Robertson 
considers it also very probable, that purely local degenera- 
tive changes in the branches of the dendrites and in the 
collaterals of the axis- cylinder processes are of considerable 
importance in nerve cell pathology." And why not? For 
as I have told you in a previous lecture, no change can 
take place in structure without that change being corre- 
spondingly felt in function even though it may be so slight, 
like the ripple of a pebble dropped into the ocean at night 
time, as not to be revealed to our vision. The chromatic 
part of the cell may be likened in its relation to the achro- 
matic portion of the neurone, to the porch of a house. The 
house does not greatly suffer if the porch gets a coat of 
paint. 

The neurones and all the nerve elements of a nerve 
center, while definitely affecting certain nerve centers so as 
to attract one's special attention there and give the symp- 



114 

torn grouping especial designation of a particular nervous 
disease, may involve other centers — certain systemic diseases 
of the spinal cord, for instance, implicating the medulla 
oblongata and other important centers without its being the 
chief location of the disease. Take for illustration, locomotor 
ataxia, called also tabes dorsalis or posterior spinal sclerosis, 
the latter to designate its special pathological seat in the 
posterior root zones of the spinal cord. Its characteristic 
lancinating pains, which show sensory disturbances origina- 
ting in the posterior column and the later trophic changes 
in the joints from trophic center invasion of the spinal cord, 
are not all of the symptoms, though they prominently 
engage our attention. In this disease we have also the 
implication of the cilio- spinal center, high up in the cervical 
segments of the cord, giving the Argyll -Robertson pupil, 
and we have the involvement of the medulla in the 
laryngeal and pharyngeal crises and even the implication of 
the fourth ventricle of the brain as shown in the vagus 
disturbance which comes on later in the disease, contribu- 
ting to cause the gastric crisis, as it is called, of locomotor 
ataxia. 

Myelitis or inflammation of the cord may also involve 
the medulla. So also may progressive muscular atrophy, 
amyotrophic lateral sclerosis, multiple or disseminated scle- 
rosis and gliosis, of which you are yet to learn much. These 
diseases may attack this vital nerve center in their onward 
and upward progress. 

Keflex functional nervous disease is also of the nature 
of extra- neural or adneural disease, as when an intestinal 
irritation excites the so-called convulsive or spasm centers 
of the medulla, as Nothnagle designated them, since contro- 
verted by Oppenheim and others. This is only the morbid 
touching of vasomotor centers whose irritation from ec- 



115 

centric or peripheral disturbance impresses the blood supply 
of the arterioles or nourishing blood vessels of the psycho- 
motor or other areas of the brain and medulla, throwing the 
brain into convulsive states* causes fainting, nausea, etc. the 
nausea itself being a reflex impression back to the stomach 
through the vagus center impression, as the head may be 
affected from the stomach, the condition causing nausea by 
sending its impressions up through the vagi or paralyzing the 
vaso-motor centers and making the brain hyperaemicas 1 have 
seen it from an intestinal tape worm. Disturbances of the 
brain from visual defects are of this nature and from sudden 
peripheral injuries such as cause fainting, nausea, etc., by its 
impression up through the pneumogastric. 

Extra-neural states affecting the nervous system in one 
part may also be the result of nerve center disorder in 
another as when the heat centers are so deranged that the 
normal balance between heat production and heat distribu- 
tion is not maintained and hypothermia or hyperthermia 
and their consequences follow. 

A good deal of see-saw reflex impression both eccentric 
and centric takes place throughout the nervous system by 
means of its wonderful central and peripheral connections, as 
you are soon to discover, as we proceed in our elucidations 
of neurology. The cerebro- spinal and sympathetic neural 
chain is a chain of many marvelous links and of wondrous 
mechanism as you will learn before you become finished 
neurologists. When we contemplate its "vast chain of 
being," "as we see it in the cerebro-spinal axis and its 
allied sympathetic and other parts of the peripheral nervous 
system, we are prompted, from a higher possession of neural 



•"Bechterew. who confirmed Nothnagle's observations, showed that these spasms 
appearing In a lesion of a definite pontine area ( vasomotor centers.') arc deriveJ from the 
cerebrum."— Mayer's Oppenhelm. 1900, p. 6Jo. 



116 

knowledge than the psalmist to exclaim, "how wonderfully 
wrought." 

Parasites and the parasitic growths which they develop 
about them in the brain or elsewhere in the nervous system 
are extra- neural causes of nervous disease like gliomata in 
the neuroglia or mesoglia between the neurones. . Echino- 
cocci and cysticerci are the chief parasites, and they usually 
attack the brain surface, causing hydatid cysts. 

Morbid involvement of the neuroglia and mesoglia are 
in the nature of extra- neural disease, coming under the 
head of what Lugaro would call inter- neuronic in contra 
distinction from intra-neuronic or within the neurone proper. 
A distinction has also been made between disease of the 
cell prolongation and of the cell itself by this author. A 
physio-chemical change takes place in an efferent nerve 
fiber, which causes a physio-chemical change in its neigh- 
boring neuroglia and adjoining neurones, which may be 
partly inter- neural and partly intra-neural. But we will 
not further discuss this subject now. 



FIG. 51. 



II 








3V\*rtiu>ww!w 



X8, 



A, spiral surface thermometer. 

B, Seguin's flattened bulb surface thermometer. 

C, Immisch's watch-shaped surface thermometer. 

D, ordinary water thermometer for bath. 

E, Landon Carter Gray's covered surface thermometer. 

F, ordinary self-regulating clinical thermometer. 



ELECTRICAL APPLIANCES. 

Besides its use in testing for the reaction or degeneration, electricit; 
is employed for the treatment; regulation and control of arteriole circulation, 
(irritating or paralyzing the vaso-motor system), restraining or stimulating 
circulation, stimulating the function of the heart and other organs, tranquii- 
Jzing the sensory nervous system and alleviating pain, (by altering the 
molecular activities and transmissibility of sensory nerves), promoting 
nutrition, destroying germs and morbid growths, electro-massage, curing 
paralysis and paresis, improving and restoring defective or lost sight (in 
Seelinblindheit especially), and for various diagnostic purposes, the latter 
Including the use of the x-ray and the electric lights in various forms of 
endoscopes r of which the polyscope is a combination. It is used In general 
as well as neurological specialties, and In most of the specialties as well. 
Special appliances for Its application are brought into requisition In special 
electro-therapeutic work, as in electro-cautery, electro-catophorests, etc. 



GaLVANO-FaRADIC DRY CELL BATTERY, 




The various forms of batteries and electrical machines and special ap- 
pliances may be seen in the illustrated catalogues of the manufacturers. 



CHAPTER XI. 

S AND PROCEDURES OF PRECISKDN IN DIAGNOSIS 
AND PRACTICE. 



The perceptive powers are enhanced by methods and 
instruments of precision in diagnosis and practice. The 
sight is improved by lenses, as when with the opthalmo- 
scope we search the inner chambers of the eye; the tactile 
sense is helped by the probe, and our estimate of sensation 
is assisted in its measurement by the cesthesiometer. The 
dynamometer helps us to appreciate the patient's grip and 
other muscular power; the degree of heat, though it may be 
felt and approximately estimated by applying the hand is 
accurately recorded by the thermometer and the calorimeter. 
The patient's power of heat appreciation is shown by the 
thermoaesthesiometer and of his sensitiveness to weight by 
the baraesthesiometer. The perimeter measures the range 
and area of the field of vision; the tuning fork and the 
acoumeter are used for testing the sense of sound, the com- 
pass points, blunt and sharp, for testing anaesthesia, hyper- 
esthesia, hyperalgesia and analgesia; the stethoscope for 
ascertaining arterial and thoracic and abdominal sounds, the 
ophthalmoscope, the endoscope and x-ray for seeing into 
the cavities beyond normal vision, and surgical sounds and 
probes for feeling beyond normal touch, etc. The constant 
current battery is used for testing the reaction of degener- 
ation, the faradic for ascertaining the degree of normal 

[117] 



118 

muscular reaction, etc., in practice. All of these and other 
appliances used by the advanced neurologist in his practice 
will now be shown you, and briefly described. 

The thermometers, general clinical, and local have 
already been shown at the end of the preceding chapter. 

fig, 52. 




For sampling muscular tissue for microscopic examination, pseudohypertro- 
phic muscular paralysis, progressive muscular atrophy, etc. A Is the handle 
with D, the blade, all ready for use; E Is a sliding receiving cylinder at- 
tached to and under the blade ready to he thrust forward to catch a minute 
piece of flesh; C is the slide button which you push forward when ready to 
secure on the cy tinder the piece of flesh; D, D, shows the blade closed 
and ready for withdrawal. 

FIG S3. 

Wv^d}«v ^Vvc**%*v* o\A\JfeY<v\* 



vo*v V»v 







Hammond was a worker in his d.iy and wrought well 
in the neurological vineyard* You will hear more of him 
from me later, Here is a. sample of his diagnostic work 
with the harpoon of Duchenne or Dtichenne's trocar, as he 



119 

called it. (See Fig. 52). The cut shows a sample of the 
muscle striae or what is left of them, taken from the lowest 
portion of the tibialis anticus of a boy in an advanced stage 
of organic infantile paralysis. "The transverse striae have 
nearly disappeared, but globules are seen in lar^e numbers 
and fat corpuscles are also abundant. ,, 

But there is not, as Ouchenne aftirms and as Ham- 
mond says, this degeneration in every case. In two cases 
which had lasted over four years, Hammond "found the 
structure of the muscle unchanged." I only show this one 
of the seven samples given by Hammond under the caption 
of "infantile spinal paralysis" to illustrate one of the uses 
of this sometimes useful little harpoon. 

It is especially of service in determining a doubtful ques- 
tion concerning progressive muscular atrophy of the degen- 
erative type, as distinguished from simpler myasthenic forms 
of muscular wasting. Hammond also in this country first 
described the diagnostic use in neurology of the dynamograph 
in the Journal of Psychological Medicine, New York, 
January, 1868. 



THE DYNAMOMETER AND ITS USES. 
FIG. 54. 




The ordinary dynamograph (from the Grrck £i»«"/us-, 
power and ypac^cii/, to write, is a dynamometer with an 



120 

attachment for automatically registering pqwer. In this 
sense the instruments of Hamilton and Burq are dynamo- 
graphs also, for they automatically register strength, but 
the medical dynamograph makes a written record of 
muscular power. The neurological dynamograph is used 
for recording muscular contractions, and is also of value 
in diagnosis. The neurological dynamograph is made 
by blending the features of a Burq dynamometer with those 
of the sphygmograph for recording muscular action. It 
transcribes to paper a record of the muscular tonus and 
power of the individual and the perfection or imperfection 
of the muscular sense. 

The use of this combined instrument is of value espe- 
cially for record of cases. But sampling the patient's hand- 
writing with pen and pencil and requiring him to make straight 
and curved lines, etc, in connection with the dynamometer 
will answer most purposes of this feature of diagnosis, 
without this somewhat expensive instrument. A healthy 
person, young or middle aged, makes a fairly straight line 
and a fairly steady signature. Incoordination modifies pen 
or pencil strokes or signatures and senility, nervous debility, 
paralysis agitans, sclerosis, chorea, paralysis or insanity are 
ofte n so marked by changed hand writing that the latter is 
diagnostic, so that the pen is sometimes as mighty as the 
knife in diagnosis. The surgeon sometimes .makes explo- 
ratory incisions for a purpose similar to that of our pen 
pictures of palsy and incoordination. Our records are blood- 
less. Their pathways are strewn with blood. 

The best of all hand dynamometers now at the com- 
mand ot neurologists is the excellent rubber bulb upright 
one Je\iseJ by Dr. Allen McLane Hamilton of New York 
City. It does not hurt a tender hand like the Burq-Matthieu's 
and does not require in its use such an extensive grip as the 



121 



latttr. Its only disadvantage is that the rubber after a time 
hardens and breaks, but the springy resistance of Matthieu's 
also weakens after awhile and impairs its utility. 

THE DYNAMOMETER. 
PIG, 55. 




One of the most valuable instruments in neurological 
tice for testing sensibility is the asthesiometer as 
devised by Sievektng, and one of the most important dis- 
coveries in Deuro- diagnosis was that "t Webber's distance 
sensation points. i 

Here is an illustration of an sesthesiometer, d by 

myself: 

THE AUTHOR'S >ESTHESlOMETER. 
FIG. 56. 

The. tual Sli* ( open 




The'polnts of this instrument fold up like a pocketkmfe. It has reversible 
add blunt points, the English or decimal scale and Weber's distance 
points engraved on it. It Is constructed of aluminum or silver and steel. 




,»P 11 FT IP 
'TIP, 



instrument 
in the making of an important discovery, 
namely, that the power to recognize two 
simultaneous but distant impressions 
(cutaneous, lingual, etc.,) varies accord- 
ing to the distance of the points of 
contact apart from each other in differ- 
ent parts, in a longitudinal line with 
the body in health. That is, there i> a 
normal variation according to the region 
tested, There i" also a compar 

tion or departure in tactile sensibility 
from the normal perceptibility of the 
points in contact with th< , when 

nervous disease exists. The tongue, 
lips, finger tips, back and palms of the 
hands, wrists, cheek, chin, dorsum, 
nucha, middle of the thigh, et 
have physiological distance perception, especially in line 
parallel with the distribution of the sensory nerves. 

Any departure in recognition of two points of the 
assthesiometer from the normal distances for the set 
localities, indicates disease, anaesthesia, hyperesthesia, etc. 
In the most sensitive parts, as tip of the tongue, palmar 
surface of second and third finger and red surface of lips, the 
points are distinguished at from half a line to two lines 
distant, while on the dorsum of the tongue and back 



123 

inch on its sides, the points must be separated four lines 
or more to be perceived in health. The distance is a line 
greater for the dorsal aspect of the second finger, the palm 
of the hand, skin of the cheek, external surface of the 
eyelids, etc., while the normal recognition distance widens 
at the zygoma and lower forehead to ten, at the lower occi- 
put to twelve and at the back of the hand to fourteen lines. 

The vortex and upper jaw require a distance of fifteen 
lines. The normal perception distance of the patella is six- 
teen lines, that of the sacrum, accromion, leg, knee and 
dorsum of foot near the toes is eighteen lines. The nerves 
of the skin of the sternum perceive the points at twenty 
lines. Over the five upper cervical vertebra? and the spine 
under the occiput and in the loins we must separate our 
points twenty-four lines distant to have them separately 
recognized by the sensory nervous system at these locali- 
ties of the back, while over the middle of the neck or back, 
or arm or thigh, only a separation of the :esthesiometric 
points to thirty lines apart will elicit distinctive recognition. 
There are other distance points, but these I have condensed 
from Weber's table and classified them so that you may 
easily remember them. 

This is a remarkable property of the sentient nervous 
system. I suppose if we could get at the fundus of the 
e ye we should find it so sensitive that it could not be thus 
measured. Sieveking's sesthesiometer consisted in adapt- 
,n 8 to a graduated measuring bar a pair of sliding points 
making a sort of beam compass, adapted by means of a 
graduated curved bar to a pair of carpenter's compasses 
and Hammond substituted a straight measuring bar. 

You may utilize a hairpin and any measuring scale 
ttat shows the inch divided into twelfths or decimals for 
approximative measurements. Two toothpicks with a Web- 



124 

er's table and measuring scale will do, but for absolute 
record, accuracy and rapid and ready use, I think the 
instrument I show you of my own devising is the best ex- 
tant. It will save the time of reference to Weber's tables 
and aid your memory as to the normal distance points. 

THE BARyESTHESIOMETER, PIEZOMETER, ETC. 

Fig. 58. 

ttTSE* * ,w ** ****** *— •*u«s%u 





An liKrunwat oVrtwd by lutoafain for uattag Um« araw of pr*a»- 
uiv in different parte of tb* bodj. it cooatau of a buttoa at UM 
*mk1 <»f * Mitral •prioff which, aa II to pf— id vpoa, curat a m 
term* o<w<Jk» oa aa lodes ,^ _. . N 

The distinguished German neurologist Eulenburg,used this 
little device tor testing degrees of the weight sense or surface 
pressure feeling. Press the button over corresponding spots 
on opposite sides until discomfort is complained of, then 
register the tender or painful spot. Practice pressing it to 
the skin of healthy persons and the neurotically hyperas- 
thetic and note the difference. It will also register degrees 
of neiiritic and other forms of hyperesthesia. Some of your 
patients cannot tolerate the static electric roller applied ever 
so lightly or the lightest Franklinic spark, because of extreme 
cutaneous hyperesthesia. Try this instrument on them and 



125 

record your observations. 1 have modified the dial by increas- 
ing in number the index spaces, and the button by enlarging 
it one-fourth in diameter. It has been of some service to me in 
determining a degree of neuritis associated with circumscribed 
meningitis verticalli. When patients come to you revealing 
sense disturbances of any kind on their cutaneous surfaces 
as heat spots, cold spots, circumscribed aesthesias or algesias 
(plus or minus) or other forms of sense hallucination like for- 
mication, etc., classed as paresthesia, it would be well to 
make also a baraesthesiometric test and other like examin- 
ations to find out, precisely if you can, the exact condition 
of the sensory nervous system as to the normal or abnormal 
manner in which it perceives cutaneous impressions. 

BEARD'S PIEZOMETER. 
FIG. 59. 



Piezometer (*■«£*«>, to press). 

Or. George M. Beard, Author of the best- known treatise 
extant on neurasthenia, also devised an ingenious instru- 
ment for testing the cutaneous appreciation of pressure, in 
examinations of the sensory nervous system, which 1 here 
show you. 

The ordinary piezometer is used for testing the com- 
pressibility and pressure power of gases and liquids. This 
instrument consists of a tube, a graduated slot, spring and 
a "d piston, with indicator thereon sliding over the scale on 
the side of the slot, to measure the sensitiveness of the 
skin to pressure. It shows the forehead, cheeks, finger 
tips and tongue to be most sensitive to pressure, and the 



126 

* 

calves of the legs, dorsum of the thighs and fleshiest part 
over the flexor muscle group of the forearm to be the least 
sensitive to pressure. 

The sensory nervous system is one of the vital organ- 
isms of the body, a part of its most important physiological 
machinery. It has important centers in the neuraxis and puts 
man in close touch with all parts of himself, within his organ- 
ism, and with his environments without, and by means of 
esthesiometry we are brought into intelligent touch with man 
in disease. For instance, the girdle and lightning pains and 
paresthetic sensations of posterior spinal sclerosis, the darting, 
painful paroxysms of neuralgia, the throat globus of hysteria 
and the aura of epilepsia. These are all aesthetic perversions, 
revealed through disorder involving sensory nerve centers. 
Slight appearing conditions of the sensory nervous system 
often have graver significance than the patients attach to 
them, as for instance the paresthesias (formications, numb- 
nesses, tingling sensations, etc.) which precede cerebral 
paralysis and the graver hallucinations of mania a potu and 
delirium tremens or epilesia. On the other hand, patients 
sometimes have apprehensions graver than the fact of 
nervous disturbance warrant, but these are usually asso- 
ciated with pain disturbance, though often underestimated. 
A persistent headache may presage a brain tumor or 
gumma, a grave meningeal disturbance; or an evanescent 
headache may indicate the slight meningeal irritation of 
transient hyperemia or a passing toxemia as after an 
alcoholic drunk; "katzenjammer" for example. 

Marre's and Pond's sphygmographs for recording pulse 
and Masso's plethysmograph and balance, devised to demon- 
strate changes in the vascular system, are likewise useful in. 
neurodiagnosis. Then there is the chronoscope for testing or~ 
measuring thought reaction time, the neuromobimeter or nervs* 



127 

reply measurer, as Dr. Joseph Warren called it; also the 
knee reflex measure and devices that readily suggest them- 
selves, as salt, sugar and pepper, for taste, and the color- 
blind tests of ophthalmology. 

The watch, the tuning fork and Politzer's acoumeter 
are used in neurology for measuring the acuteness or dull- 
ness of hearing in certain suspected brain diseases and 
for topical diagnosis in cerebrology. By them we may 
be aided in locating tumors of the interior of the brain, 
as the ophthalmoscope also aids us in this particular, but 
not so much as the eye symptoms independently of what 
the ophthalmoscope reveals. 

OPHTHALMOSCOPE, NORMAL AND ABNORMAL 
EYE FUNDUS. 

These illustrations show for comparison the normal 
and abnormal fundus of the eye and the instrument by 
which they are revealed. 

The chief value of the ophthalmoscope to the neurolo- 
gist is in the determining of the existence of optic retinitis 
°r choked disc, evidencing blood pressure or altered circu- 
lation in the brain states caused by tumors gumma? within 
the cerebrum or cerebellum. 

Optic retinitis is associated also with the interstitial 
ne Phritis of morbus Brightii, which very often is a sequen- 
tial condition of profound brain strain, in my medical 
ex Perience, as are also the tube casts so often found coex- 
isting with the albuminuria. 

A good deal of practice will be necessary before you 
tecome sufficiently expert to use the ophthalmoscope as an 
instrument of diagnosis of intra-cranial disease. If a thor- 
°ughly expert ophthalmologist is convenient to you, 1 would 
a<J vise you to call him to your aid where the nervous 



128 

symptoms may lead you to suspect a cerebral tumor or 
other serious brain disease, or when you have that nervous 
breakdown which precedes and goes with tube casts and 
albuminuria and where you likewise should look for con- 
joint and confirmatory optic retinitis. The fundus occult is 
likely to befriend you, if you take it into your confidence 
in the diagnosis of these grave brain nervous system 
conditions. 

Our lamented colleagues, Drs. Murrell and Dickinson, 
in the chair of ophthalmology, and their able successor, 
Dr. Henderson, have been of signal help to us in this 
sphere of cooperative neurodiagnosis, as have Drs. Green, 
Post, Alt, Saxl and others of this city and elsewhere. 



LORING'S OPHTHALMOSCOPE. 
Fig. 60. 




129 



NORMAL KM B HI 
FIG. 61. 

" t 






nasal 




Md san 9* 



n 86 p argn 



—Head of the Optic Nerve, 
haukoscofic View.— Somewhat to the inner side of the center of the papilla tli- 

rises from below, and to the t« mpora! side of it rises the central vein. Ar the 

ifler lies the small physiological excavation with the gray stippling of 

J he papilla le encircled b> the light scleral ring (between c and cf), and 

lal ring at ri. 

m tiox THHoroH thj HftAD or t^e Optic Nerve Magnified 14 * 1.— The 

e up to the lamina cribrosa has a dark color because it consists of medul- 

Idch have been stained block by Weigert's method. The clear inter- 

space*, *■*, separating them eorre«|iond to the septa composed of connective tissue. Tl*e 



trunk is enveloped by the nheath of pia mater, p, the arachnoid sheath, fir, and the 
lib of .bira mater, >iu There fs a f ri«e interspace remaining betwess the sheaths, eon- 
I tte subdural space, nrf, and the subarachnoid space, sa. Hoth ftpaces have a blind 



■r»at r The sheath of dura mater passes into the external layers, to. of 

of pta mater into the internal layers, jm, which latter extend as the 

irn*a transversely across the course of the optic nerve. The nerve is represented 

thr- lamina as <f light color, iHrcauae here it constat* of non medullaled and 

it nerve- fibers. The optic nerve spreads out upon tlie retina, r, in such a 

way that in it* center there i* produced a funnel-shaped depression, the vascular funnel, o, 

oner wall the central artery, a, and the central vein, p, ascend. 

: ansverse section of its numerous blood-vessels, and toward the ret ma a dark line, 

helium; next the margin of tli« foramen for the optic nerve and correspond* 

'" the situation of the chorioldal ring, th** chnrioid is more oarklv pigmented, ci t»a 

pawl- artery which reaches the cbortoid through the'sclera. Between the 

and the margin of the head of the optic nerve, c. there is a narrow 

the sclera Lies exposed, and which corresponds to the scleral ring visibh 








--Optic Nmnns (Cbomd Disk).* 
A, Ophthalmoscopic View of this Papilla, Magnified J 4 * l,— The papilla appear* 
em hi v enlarged and without distinct outline, It is of a grayish white color, clou* 
covered with radlatto k>leh >xt*nd into the adjoining retina The retinal, 

a, a, are contracted, the retinal veins, v, r, are exceedingly dilated and tortuous, and 
hazy In places. Adjoining the papilla, radially disposed, striate, red spots <ho?mor 
A, are found in the retina. 
B % LDNamrORCAL Bvction turouor the Head of tfte Optic Nerve.— This is greatlv 
SO as to project above the level of the adjacent retina and form at the naae an annuU 
faction, the neurit ic a welling, n. There is a cellular inflhrntMii, particularly along 
nuter blood vessels, r, for which reason the latter stand out with a special pron 
retina, r, is thrown into folds about the circumference of the papilla, in consequent 
swelling of the latter ; the chorlold. rh, ami the sclera, .«, are normal, as is th 
posterior to the lamina cribroao,. Here there simply exists a ddalai Ion of the intei 
space, i, through accumulation of fluid, in virtue of which the greatly folded ar 
sheath, ar, is especially well marked ; du t dura I sheath ; p f plal sheath/at^e* f*4 



131 



FIG. 64. 



A cautery is an apparatus founded on the property possessed by plati- 
num, when heated red hot, of remaining incandescent as long as the vapor 

of a hydro- carbon is projected upon it. 
A hollow piece of platinum, varying 
in shape according to the purpose in 
view, is attached to a tube connected 
with a reservoir of benzin, the vapor of 
which is pumped into the hollow of the 
piece of platinum (previously heated in 
the flame of a spirit lamp) by means of 
a hand bulb. (Foster.) Bruce in Eu- 
rope and J. J. Putnam in this country 
^^^ have modified this into a gas cautery. 

*titt^ ^^B L^ _ Pacquelin's cautery is especially used 

^^^fe_^&_ ^^^^^k f° r producing counter irritation in spinal 
^^Br^^m cord disuse. 

If gasoline is considered objectionable or too inconvenient and gas is 
handy the gas instrument of Dr. J. J. Putnam, of Boston, is an improvement. 
But the Pacquelin cautery or McLane Hamilton's substitute for it, in places 
where gas is not procurable, are our main reliance for thermo-cautery in 
treatment of spinal cord disease. Actual cautery is a substttute for the 
moxa and blisters. 

Where a contrary (cooling) effect over the vertebrae or cranium is 
desired, strong chemically pure ether lotions or sprays may be employed, 
saturated if desired, with menthol. 




Stereognosis is the ability to recognize the shape, size 
and other properties of objects through the sense of touch 
and feeling (orc/xos, solid, yiwmt which signifies to know). 
Asteriognosis is a modification of the tactile sensibility and is 
especially valuable in diagnosis in the line of a person's 
trained knowledge as to the form, size and weight of objects 
he may have been accustomed to daily handling. As for 
instance, a grocer with scale weights, eggs, potatoes, a 
bank paying teller with bank notes. The latter would 
hardly be a good test for doctors. 

If an individual cannot recognize the form, size and 
weight of objects with which he is especially familiar by 
daily routine practice, (a doctor with a hypodermic syringe or 
a surgeon with scalpel or needle), for example, grave an- 



132 

aesthetic or paresthetic mischief might be suspected and it 
he called them something very foreign to their real nature, 
as snakes, lizards or other reptiles or some insect, sensory 
delusion pointing to cortex lesion would probably be present. 

The luemoglobinometer, the urinometer, the microscope, 
the test tube, the endoscope, the pleximeter, the stetho- 
scope, the atoscope, the laryngoscope and other cavity 
speculi, etc., are all of use in diagnostic neurology, as they 
are in other departments of diagnostic medicine, but as they 
are shown by the other chairs we need not specially de- 
scribe them. For diagnosis by exclusion the neurologist 
must sometimes use the surgeon's sound aspirator and 
probe and, even sometimes he may have to call in the 
surgeon to make exploratory incisions, and the surgeon 
would likewise do better in diasnosis than he sometimes 
does in conditions connected with nervous women if he 
would also oftener summon the neurologist to aid him 
in some directions in diagnosis connected with these uncer- 
tain creatures with uncertain diseases. But mutual diag- 
nostic aid in these matters is gradually coming about with 
the most intelligent practitioners as knowledge broadens 
and our great science advances in its power of exactly de- 
tecting morbid conditions. 

CEREBRAL TOPOGRAPHY CASTS. 

Casts are used in neurology for refreshing and increas- 
ing our knowledge of surface regional brain anatomy, es- 
pecially in making out cerebral localizations. Casts like 
those of His are also of great value in the study of em- 
bryology, as are also the wax figures of the nervous sys- 
tem and atlases like Flowers' and others, to hang on your 
ofti/e walls and keep the anatomy of the nervous system 
ever before you, and thus prevent it from fading from your 
mem«>rv. 



133 



CEREBRAL TOPOGRAPHY. 

FIG. 65. 

tA*tvcCtw4\va«*fc War. t\Wwfvo^V«^Q>T»Wv»-^«r^bT^Xlo^o^t;a^ 



Vjrnvr front*} 




id-tft/t-nwtai 

pcrmWJb**m 0r.fln( 

jfowrt. 
ipbiMil JUturt. 



FIG. 66. 
Wmmk» Knee-$€rfc Reinforcement mdFKod 




FIG. 67. 

Metliod of apply- 
ing the dynamometer 
to the foot. 




134 



FIG. 68. 



FIG 69. 




^gpsfe 



FIG. 70. 





FKi. 71. 



BwaAmAWJ. •• LWrffvo* 




The tips of the fingers, or sides of the open hand, or 
a narrow book or ferrule may be used, in lieu of a 
pleximeter, for eliciting the knee-jerk and other reflexes. 
You get the ankle clonus better by grasping the foot nearer 
the ends of the toes than is illustrated in the cut and by 
resting the calf more lightly on the other hand than is 
shown in the illustration. The Jendressek reinforcement is 
further reinforced by having the patient shut his eyes and 
by placing him on an uncovered table that has no slanting 
cushion or padding of any kind on it and by having the 
patient incline Ms body forward with the eyes shut as you 
make the knee tap. 



135 



FIG. 72. 

CYSTOSCOPY, n. Lai, natoteopium (from c*V- 

rw, the Madder, sad mmtm', *o famine), rr.. e. Uer\tyrfoalnm.- 
An tntfnrawBft for the ocular examination of the Inferior of the 
arinary bladder. Nttaa's c constate of a closed tuba with windows 



Wall of the bladder. 




through which a pencil of lirtt from a loop of platinum wire ren- 
dered lncandusceut by a galvanic current may be thrown by the 
aid of a priem, and through which the observer views the vesical 



mucuua. nembrane, the whole being surrounded by a larger Uiba 
through which cold water b kept flowing. IW. Meyer, •• N. Y. 1* " 



You do not need to become as expert as my friend and 
former pupil, Professor James P. Tuttle, now of New York, 
in the use of the cystoscope, for its use belongs to his 
daily, even hourly, business, but you should know enough 
about what it may reveal, to be able to diagnosticate by 
exclusion a neurotic from an organic disease of the bladder. 

There are various modifications of this form of endo- 
scope, one excellent one by Dr. Bransford Lewis, of this 
city. But I need not go further in the description of this 
instrument of precision in diagnosis, as it is not used 
chiefly for neuro-diagnosis, except as I have said for the 
excluding of the possibility of organic bladder disease or 
of finding it associated with nervous disease, as it and the 
whole genito- urinary system are sometimes associated with 
extreme genital hyperesthesia, making life miserable and 



136 



even beyond the resources of our ordinarily exceedingly 
resourceful coadjutors, in practice, the genito-urinary special- 
ists. My genito-urinary colleague Dr. Boogher may en- 
lighten you further on this subject. Dr. Phillips is also 
au fait in this business, and so is Bryson. They all come 
to our aid sometimes in confirmatory diagnosis. 

fk.. 73. 

5Wt rtvo cyyj* l« R« »i Mg »» 




The perforated holes in the straps are for receiving the Seguln surface 
thermometer when head heat measurements are being taken. 

The u^es of this adjunct to cerebral thermometry sug- 
gest themselves. These straps should have been shown 
you when we were on the subject of cerebral thermometry. 

PERIMETER AND VISION FIELDS. 
FK,. 74. 




- U*-»'itpr» |«n-ot«tr. 



A periir.ctei is an instiunu-nt tor finding and mapping 
out the vision fields. 










Fields nt vision recorded by the perimeter are called 
metric field charts, but the vision field is not called the 
perimetrium. The perimetrium has an entirely diff 

ll is the peritoneal covering of the womb. 

76. 




OlCo 






Fki. 77 







hSltK ) 



CHAPTER XII. 

INSTRUMENTS OF PRECISION (CONTINUED). 

WILSON'S CYRTOMETER perforated with holes and 
the stem of a Seguin surface thermometer passed through 
them to its broad expansion and the latter applied next to 
the skin might be substituted in head heat testing for 
Carter Gray's thermometer straps. It could be thus used 
to serve the double purpose of locating cerebral motor 
centers and excessive heat spots in the brain. 

Wilson's Cyrtometer was first described in the London 

Lancet in 1888 by A. W. Hare March 3rd, page 407, and is 

fully illustrated and defined in Foster's dictionary. The 

name is formed from the Greek xi-pros, signifying convex 

and fierpav a measure, meaning a device for measuring 

curves. Callipers come under this definition and can be 

used for measuring the curved surfaces of the cranium and 

for locating the psychomotor centers of the brain. But this 

device of Wilson's is a special one for readily locating the 

fissure of Sylvius and approximating the fissure of Rolando 

and the centers grouped about the Kolandic area or motor 

center area of the cerebrum. Cyrtometrum is the Latin 

term, the French use the same term, but the Germans 

have a less euphonious sounding expression for it. They 

call it lYolhtngomesscr, which means better than it sounds 

to American ears. It signifies a knife to cut curves with. 

But you miht "get onto the Gel man curves" of language 

to appreciate teims like these. 

[138] 



139 



THE CYRTOMETER. 
FIG. 78. 




▼oaoii'i ctrooto. Urna ham, I. c.) 

f'iri. 7<>. 




wiUKMtm cTirroram applrs. 
Umi sabs, /. c) 



The broadest transversa strip of the cyrtometer passes 
coronally round the forehead, corresponding with the gla- 
bella or hairless space between the eyebrows, as its origin, 
(glabellus, implying hairless, )and the external angular process. 
The narrower longitudinal strip passes backward from the 
glabella in the middle line to the occiput. This strip is 
marked with two scales of letters; capitals in its posterior 



140 

fourth, and small letters about the middle of the strip. 
These two scales bear an exact relation to each other, 
calculated to suit in the application of the instrument t<> 
the ordinary head. Measured from the glabella backward 
to any given small letter is 55.7 per cent of the distance 
from the glabella to the corresponding capital letter; thus, 
when any capital letter falls directly over the inion ("«»», 
back of the head or external occipital protuberance), the 
corresponding small letter will coincide with the top of the 
fissure. A third narrow reversible strip slides on the lon- 
gitudinal strip of the metal, marking an angle of 61° open- 
ing forward, and marked at 3 ; 4 inches from its attached 
end, thus giving the length and direction of the tisMire mi 
the surface of the head. 

CRUSH'S DIABETOMETER is a half shade polariscope 
showing one gramme of sugar to the litre of urine. It is 
an instiument whose use, like that of the test tubes and 
modern sugar test papers, comes within the scope of 
neurological practice and diagnosis. It is important to 
know whether or not there is sugar in the urine. For 
besides the intimate association of diabetes with coma 
and comatose states, with diabetic melancholia and hypo- 
chondriasis, vari« us other nerve center states engender or 
are associated with diabetes. It appears often in connection 
with giantism and acromegally. The sugar test of the 
urine, its presence, its absence and its recurrence, like that 
ot albumen in the progress of ceitain neuropathic conditions 
ot the .eiitr.il i. eivoiis system, may enlighten you as to the 
progress, upward or downward, a case may be making. Look 
loi it> presence in the mine in all cases of profound nei\e 
• ■enter sh,,/|< f especially in the great psychic shock of An 
overwhelming business leverse or of an overmastering sor- 
row, alter a severe and prolonged strain of vigilance, or of 



141 

business or great loss of sleep, terminating in profound 

depression of spirits that will not be eased or comforted. 

And you will sometimes find it where the books do not 

direct you to look for saccharine urine. Melancholia and 

diabetes me Hit us or glycosuria are often found intimately 

associated as 1 have said. Profound nervous exhaustion may 

engender both. Thinking as a neurologist I would designate 

tlie associated urinary phenomenon as nerve depression 

or psycho-neural diabetes, but it is often called diabetic 

melancholia, putting the cart before the horse or the liver 

before the fourth ventricle and associated nervous system 

as t>eing concerned in the morbid metabolisms that permit an 

excess of sugar to form and get into the blood and out 

through the kidneys. You may put the hcepatic cart 

( glycogenic liver ) before the neurologic horse if you 

vant to, but remember the fact of the frequent association 

of profound cerebro-psychic depression and sugar in the 

urine and look for the latter and remedy it, not only by diet 

but by brain rest and a new exhilarating, diverting, restful 

Psychic and better physical environment for your patient. 

Codiae, nux vomica, chloral, laxatives, good nutrition and 

hepatic and systemic tonics will help also. 

The essential pathology of mellituria or diabetes has 
n °t been located. It is not in my judgment primarily in 
the liver. It is not in the kidneys. The sugar accumu- 
ates in the blood and is called glycoh:emia. Some altera- 
10n has taken place in the metabolic processes and 
fcycohjemia and glycosuria are the results. Behind there 
are nerve center changes which have not yet been eer- 
ily located to the satisfaction of pathologists. Having 
een glycosuria come and go in the course of grave nervous 
e P r ession and keeping in mind the fact that irritation of 
e floor of the fourth ventricle develops it in animals, 1 



142 

look upon diabetes mellitus revealing glycohaemia con- 
sidering the many melancholiacs in whom I have seen it 
appear, as a brain strain sequence in many if not all 
instances. The amount of glucose in the urine may reach 
from eight to ten per cent in grave cases. And such grave 
cases usually become chronic and fatal, though 1 have had 
an occasional recovery where the saccharine polyuria was 
excessive and the melancholia profound. 

When the water dribbles from your patient's bladder 
or passes involuntarily in larger quantities, or passes vol- 
untarily too often or will not pass at all, or passes during 
sleep, (eneuresis) or if a constant desire to micturate exists, 
it is important for you to be assured that no organic con- 
dition exists to cause the trouble. A belladonna or opium 
anointed catheter with bromide of potassium and acetate of 
potash, etc., internally, will help these conditions if only 
neural hyperesthesia and a heavy irritating urine are the 
causes. But the cystoscope will aid you in assuring your- 
selves whether the fault is only in the bladder. A cyto- 
scope will help you in neurology as well as in grneral 
medicine and surgery. Accustom yourselves to see as far 
into and through your patients as you can and you will 
escape the reproach and help to spare the profession one 
of its chief reproaches, namely, that of inadequate and 
complete diagnosis. They are made in neurology as well 
as elsewhere. 

THE DETECTION OF ABNORMAL SENSATION. 

Hallucinations are false perceptions of sensation. The 
hallucinations of the special senses of sight, hearing and 
smell, connected with disease of their special sense centers, 
as in epilepsy and certain forms of insanity, have been 
well studied, as well as the special nerve center and per- 



9 

i 



143 

iphery changes that lead to real disorders of sight and taste 
and hearing. Disorders of the general sensory nervous 
system, too, as 1 have told you in a preceding lecture, have 
received some consideration, giving us the anaesthesias, 
hyperesthesias, paresthesias, etc., recorded in the literature 
of neurology. But exact measurements of these abnormal 
impressions or false sensations, that is, methods for detect- 
ing whether they are real or not, whether they have a local 
cause or result from sensation disturbing disease in or near 
the centers of sensation in the brain, have not been so 
well studied. Disease in the lower part of the corpus 
striatum, one of the basal ganglia, may cause alterations in 
Peripheral sensation. Spinal cord center disease likewise. 

In psychiatry which is the study of mental aberrations § 
2 r eat pains are taken by men who aim to be certain and val- 
uable in their opinions, (and all should so endeavor in so 
irn I>ortant a matter), to be sure that the apparent delusion 
,s riot really a fact of the body and not a fancy of the 
rn ind; though delusion is, however, an impression on the 
£ r **y cortex of the brain deceiving the mind. If a patient 
has formication and slaps himself and you find on examin- 
a ^on that his bed or body is really full of bugs which 
disappear when lights are lit, he is not "buggy" in the 
slang sense of that abominably vulgar synonym for insanity, 
"Ut he is really and truly buggy, and the remedy consists 
lr * treating the bugs and not the patient. So too, a patient 
. ^ay imagine pediculas and have them on his person or 
Itla y have lately had them and the mental impression still 
abides as it will sometimes for several days after. The 
" rs t impression would be no delusion. The second would 
e ^n illusion persisting after the exciting cause is removed. 
Do you remember the first time your good, tender, 
P a tient, loving, anxious mother found the hirsute of your 



144 

caput in the possession of a tribe of pediculi and went 
through your tiair with a fine-toothed comb, how you felt 
for several days after the enemy was cleared from the 
field as if they were still there, though you had faith 
in your mother and knew she would never let an enemy 
to your peace and comfort and rest and happiness of that 
kind escape her comb while she had breath and power to 
wield it? The first sensation was the real thing. You 
had them. The second was an illusory impression. Some- 
thing had been there to excite the impression. You believed 
they were still there but actually they were not. That 
was a delusion pure and simple. You got them from the 
boy you had the scrimmage with. That was no delusitm. 
You thought you got the better of him. That was a delu- 
sion, for though he got the licking you got the pedicuLe. 
The scratch was on you. Such is life in our boyhood 
day*. It has its illusions, hallucinations, delusions, even 
rationally founded, as later periods of life have. Later in 
the session I will tell you what morbid cortex hallucinations, 
illusions and delusions are and how we mav distinguish them 
from deceptions that are rationally and healthily founded. 
The subject is a moving and timely theme for profitable 
discourse, and irrational delusion must be rationally studied 
by the physician. 

It is well to test the discriminating sense or power of 
perception of the sentient nervous system in various ways. 
For while the sensory nervous system, when it or its cen- 
ters are diseased, reveals hallucinations of insects or snakes 
creeping over it, or of water being poured over it or upon 
it, or hot or cold air being blown upon it, scalding, burning, 
freezing sensations, when surrounding temperature does not 
account tor these feelings, the absence of power to detect 
real impresssion of this sort sometimes exists in varying 



145 



states of anaesthesia. You may try artificial formication; 
draw hairs or fine wires or strands of silk over the cuta- 
neous surface to ascertain if the sensory nerve endings 
properly recognize them and the peripheral nerves transmit 
the right impressions of their presence on the surface to 
the brain. This will help you in diagnosis of nervous 
disease. 

fig. 80. 



23 22 



20 19 



AMERICAN SCALE. 



OOOOOO 

o 

o 



GoWeteT GuaqpS/ Pvt^tYomfc* 



1 * 

2 o 

3 o 

4 O 
SO 

«o 

*o o OOOOOOO 

8 9 10 11 12 13 14 15 

^— > 

/,Z. 3. ^CxvVvoXa 6n^Cvc>, ^w?VX C/uvtiv). 



A pupilometer will aid you in measuring the size of 
ne pupil, and in estimation of its variations from the nor- 
a * in form. For this purpose a catheter graduate card 
or scale will answer every purpose, though some neurolo- 
gists use a special device like the one I show you. 

The pupil dilates after division of the motor oculi nerve, 

0r *tracts after division of the cervical sympathetic and from 

isease affecting the centers whence these nerves arise and 

Proceed to the pupil from brain or cord. The pupil is also 

a *tered in size and shape by disease involving the sight 

aTe as of the brain, the optic tracts, the cilio- spinal center. 



146 

Disease implicating the iris, like iritis, the lens, like cata- 
ract, the chambers like glaucoma or the retina like paraly- 
sis and amaurosis, change the appearance of the pupil. So 
that here, as elsewhere in neurology, your diagnosis must 
be differentiated. 

The Rhomberg symptom of swaying forward and 
from side to side when standing with the feet together 
and the eyes shut, one of the locomotor ataxia signs, may 
be measured by a light bar attached across the head, 
and so arranged as to slide over a scale frame like the one I 
show you or by the ataxagraph, a cut of which you may 
see in Dana's invaluable neurological text- book. Exact 
measurement of this sign is not very essential, except 
perhaps, for record in certain cases and for comparison. 
Still it is well to have some means of exact record and 
comparison. 

THE MUTAMETER, MOVEOMETER OR AMEBIMETER; 
A MOVEMENT RECORDER. 

Two adjustable bars wide enough apart to permit the 
head to rest and sway some between them are secured 
across a hoop. On these bars are secured carpenter's 
scales. A band is adjusted to the head with front and 
lateral roller secured to them firmly and resting on the 
bars. The degree of to and fro and side to side tremor is 
shown in the movement record on the scale. An arm from 
the top band on the head with a pencil attachment makes 
a movement record of the tremor also on card-board 
between the bars and the hoop walls. This instrument 
may be adjusted to the feet also to guage impulse, knee- 
jerk and heart foot tremor. 

You may construct a moveometer out of a cyrtometer 
and a scale graded frame by attaching square cork blocks 



147 



? sides of the fronto-occipital band or the glabello- 
band, as it is more technically called. These blocks 
to and fro and from side to side on the scale bars 
le range of tremor or swaying movement of dissemi- 
and posterior spinal sclerosis are thus shown. 

fig. 81. 



YlUrtu 




AAA A H».p. aa&wJ C.C. RuW tpocc* •«. w**»*b** ^J 
*4~**W r^ f .*Wt, AMD. Or* p^WU. f .„ t uv^ £1* 
?•••, C. 0»UtU .«.W«4.. F.F Jfc*/W*4 Av«..wa».C^&G.O«« 
•r** ft XT**, HM.HKOc»c«tV^^»ctU«>v«4.<.W^i 

aU * J »**•*• <•* •? KW. c.^^*cX»A oX «*W %\U WW 



CHAPTER XI11. 



INSTRUMENTS OF PRECISION (CONTINUED). 
THE SPHYGMOGRAPH, THE PERCUTEUR AND THE POLYGRAPH IN PRAC ~*"~" 1CE 

Each left ventricular contracture, or systole as it ,s 
technically called, of the heart, sends a wave of bloo*i 
and onward from the aorta, causing a raised arterial -t^ n " 
sion extending on to the capillaries. This pulse wav*^* l 
measured, in medical practice usually at the wrist over ^ 
radial artery, either by finger or instrumental touch. 
may be measured wherever the artery is sufficiently sup^^ r 
ficial to touch with the finger or permit the adjustmen *: 
an instrument to it. The velocity of the wave pulse va *" * 
from four (4) to twelve (12) meters per second and its io *~ 
varies from four ounces to one pound or more. Richerr* **"* ' 
the old French physiologist first measured the force of ^ 
heart's lifting power by adjusting weights to the foot 
one leg crossed over the other at the knee. 

The proper term for a pulse measurer is pulsometer ** 
pulsimeter, but these terms have been appropriated * 
mechanics and as medical science needed also the use of 
combined recording and descriptive instrument, fAar^ 
invented the pulse measure which he called the sphygmfr 
graph. A sphygmograph therefore is a recording pu\somete~~*~ 
the motor force of whose mechanism for all devices up \CZ^ 
the present date is the pulse or circulation impulses of the 
artery to which the instrument is attached, the fundamental 



149 

try pulse resulting from the primary ventricular 
in Impulse causing the initial movement stroke 
the pulse curve, aided by clockwork adjustment. Tlie 
ondary pulse wave follows the primary curve and is due to 
the elastic nature of the arterial walls, It is indicated by 
a secondary elevation following the initial upward stroke of 
the pulse curve as the lines on the sphygmogram show. 

FIG 82. 

Mne J/liqaeon- \aly<xmc^T-cLfi/^ 



The term sphygmograph, {from the Greek <7<£i7/a<«, the 
pulse, and ypnv4>ut> t to write,) is an apparatus, as you 
now prepared to understand, designed for measuring mid 
j the blood pressure in the arteries and the var la- 
in the heart's beats as shown by the pulse. It usu- 
ot a lever or a system of levers placed upon 
the and connecting with a registering apparatus, 

due in diagnosis depends on the fact that the heart 





150 

and pulse beat are usually synchronous. Sometimes the 
heart's beats and pulse beats are not synchronous — they 
are asynchronous and this is not a good omen in diagnosis. 

The cardigrahh measures the heart beats and the 
yolygraph combines the features of the cardigraph, sphy- 
gmograph, etc. 

The sphygmogram is the tracing and also the name of 
the slide showing the record of the sphygmograph as dis- 
tinguished from the sphygmograph itself. The sphygmogram 
is traced on mica, as with Pond's sphygmograph or on 
paper as with others. This tracing makes for the normal 
pulse wave a curve showing an abrupt rise (primary eleva- 
tion) followed by an abrupt fall, after which succeeds a 
gradual descent, more or less interrupted by secondary ele- 
vations. The primary elevation (percussion wave) and the 
first secondary elevation (tidal wave) correspond to the 
systole, the third (dicrotic elevation) and fourth wave to the 
diastole of the heart. The paper or mica used for the 
sphygmograph is blackened by holding it over a smoking 
lamp and the tracing moving in accord with the pulsations 
of the artery, indicate the strength, rapidity and conformity 
or otherwise of the pulsebeat. 

The most important matter connected with the use of 
this delicate instrument of precision in pulse testing, after 
accurate and perfect adjustment is to guard against the 
normal tremor and jerky moevments of muscle strain and 
muscle tire and recording the same on the tracings of vour 
sphygmogram as abnormal puKe movement. To this end a 
complete arm and wrist rest must be secured before or 
after fettering the wrist with the stiap and buckle prepar- 
atory to taking a record of the pulse wave. Some sphyg- 
mographers have not duly guarded against this complicating 
and confusing factor. The fingers should also be kept 



151 

quiescent, as their movements effect the*tracings and'like- 
wise, with arm tremor, may become deceptive tracings which 
might be recorded as belonging to the artery whereas the 
fault would really be with the muscular tremor. To secure 
the fingers, rubber bands had better be placed about"them, 
somewhat as we do in steadying them where pen paralysis 
exists, except that all the fingers of one hand should be 
embraced in one band, before applying the button over the 
pulse to receive impressions. The hand should be kept 
steady, as hand movements as well as finger movements, 
and wrist movements, will effect the tracing on the sphyg- 
mogram. 

The sphygmograph is a valuable aid and supplement 
in diagnosis to the stethoscope, pleximeter and thermome- 
ter. Its tracings are almost as valuable and certain, though 
requiring extreme care in recording them, as the revelations 
of the speculum or endoscope. In direct and accurate 
differential diagnosis, neural as well as general, its use is 
sometimes indispensable and always a satisfaction, if you 
have the time, opportunity and skill to use it rightly. But 
you should not attempt to supplant the skilled touch of the 
fingers with this instrument. The tactua cruditus in neu- 
rology is as essential as in surgery or physical diagnosis. 
Like the bruit of an aneurism and the sound of ancrmia to 
the skilled ear, the touch of the full bounding pulse of 
hyperemia, and feeble, small short pulse wave of anevmia are 
matters of skilled perception which no machine can impart. 
The finger record of the fluttering, quick, irregular, shal- 
low wave pulse of approaching dissolution is as unerring to 
the mind, through touch, as the tracing of the sphygmo- 
gram. They both tell their tragic talc of the near ending 
of mortality as unerringly as the incoherent delirium of 
impending somatic dissolution. 



152 

The sphygmograph gives you a pulse record. It reveals 
arterial degeneration states as in cerebral and other arterial 
scleroses. It records states of altered cardiac innervation 
as in dropped beats, swtft beating tachycardia, slow beat- 
ing bradycardia, etc. 

The sphygmograph is a good means of testing the 
action and efficiency of medicines. 

It is good for making comparative records of the two 
sides and of the pulse of the extremities with the heart's 
beat. It is useful in diagnosticating aneurisms, an;rmia, 
hyperemia, sclerosis. It should be used more than it has 
been for recording the pulse of and sequent to shock, the 
pulse of neurasthenia, exophthalmic goitre, the pulse of 
general paresis, hypochondria, melancholia, chorea, epilepsia, 
hystero-epilepsia, mania, etc. Dr. Francis S. Kennedy, in 
a recent valuable and practicable article*, introduces some 
pertinent tracings, which are here shown. 

THE PEN-HOLDING, TREMULOUS HAND ATTITUDE OF 

PARALYSIS AGITANS. 

(After Eichhorst.) 

FIG. 83. 




•The Sph>fcmocraph. Its Practical Value." Brooklyn Medical Journal, July. 1902 




a/v\a)\ 



fWW^7v\A 



-Ay 



Ten Seconds, 





A COMPARATIVE SERIES OF MYOGRAMS OF TREMOR. 

1 T Paralysis agttas; 2, Basedow's disease; 3 t multiple sclero^** 
hysterical tremor; 5, neurasthenic tremor; 6, delirium tremens. 

Tremors modified rapidly recurring ruincature spasr** 
as Peterson says they "are a modification <>t the rhytl 1 
ic discharges of energy from tlie motor ganglion cell^ 
lich occur at the rate ul ten per second. Consequently^ 



155 

when we have fewer per second, it is because of fusion 
of two or three impulses." 

Petersen found the tremor vibrations in various dis- 
eases at his nervous clinic to be "from 3.7 to 5.6 per sec- 
and, thus agreeing with all other investigators excepting 
Gowers." 



FIG. 86. 

E, in. the figure, shows 
the connection with the 
battery. A regulates the 
length of the vibration, 
and. J$, C and D, are 
appliances which only a 
study of this instrument 
itself will render perfectly 
clear ; pressure on F sets 
the percuteur at work. 
Other vibrators accom- 
pany the instrument be- 
sides the one seen in situ. 
Dr. Granville began his 
observations using clock- 
work, instead of electric- 
ity, but forbffice work he 
prefers electricity, and 
uses the clock-work only 
at the patient's house. Dr. 
Granville uses the percu- 
teur in locomotor ataxia, 
some cases of chorea, for 
the relief of cerebral and 

cerebrospinal irritation and distress, and to elicit energy 

from torpid centers . 




An American substitute tor the pei\uteiir is the vibra- 
tile. It is less expensive and answers quite as well !«»r 



156 

ordinary purposes of nerve excitation. The principle of its 
construction and action are the same, vi$. t power, and in- 
both instruments electric power, converted into vibratory 
motion and this vibratory impression applied along the 
course of a nerve or over a nerve center, if one could be 
reached with it, as for instance a vaso-motor center, with 
a view of bringing about a change of action in a morbid 
nerve. It acts as a sort of a mechanical counter irritation 
and massage combined. This principle may be applied 
successfully for the relief of pain and improving nutrition 
in a part, and it is a good method to use in the relief of 
spinal irritation and tender spine in women, for suggestive 
psychical effect and for spinal myalgia, which is often a 
morbidly sensitive condition of the sensory nerve endings 
in the muscles along the spine. 

When in practice you need to stimulate and change 
molecular activity in a peripheral nerve, employ the per- 
cuteur, the vibratile friction or other mechanical or chemical 
irritation. It will probably some day be brought into use, 
with suitable adjustments, for the purpose of influencing 
the brain through the eyeball and the ear, as nerve 
stretching and electricity and excessve peripheral nerve 
irritation effects the respective peripheral nerve centers. 

There are many other instruments and appliances to 
minutely satisfy scientific curiosity and interest in precisely 
diagnosticating states of your patients' system with which 
you may wish to become familiar after graduation. Among 
these are Huter's cheiloangescope, a microscopic adjust- 
ment for seeing the living circulation in the lip. Another 
is Antelme's cephalometer and Zernoff's encephalomett-r 
which you will find illustrated in Foster's Dictionary. The 
circulation in the human ear and in the frog's foot may 
also be seen with a microscope and suitable adjustment. 



CHAPTER XIV. 

ASCENDING AND DESCENDING DEGENERATION. REACTION OF DEGEN- 
ERATION; WALLER'S LAW; ITS DIAGNOSTIC SIGNIFICANCE. 

If a lesion involve the neurone or neurones of a motor 
center, up in the gray cortex of the brain, for instance, in 
any part, where those fan -like striae called corona radiata 
and projection fibers pass down to go through and between 
the two great basal ganglia especially, through the corpus 
striatum in that contracted white bundle of fibers which we 
call the internal capsule, which proceed down and contrib- 
ute to make the cruri cerebri or peduncles of the brain, as we 
have so often pointed out to you in our dissections, and 
which fibers go mainly to make up the direct and crossed 
pyramidal tracts of the brain and cord, sending some fibers 
down the cord directly, but chiefly obliquely across and down 
the cord In what is called the decussation or crossing of its 
pyramids or corpora pyramidalia, and neurone degeneration 
begins up there in the cortex, this degeneration goes on 
downward until it meets with the first sub- station or lower 
motor center in an anterior horn of the cord. All of the 
motor fibers connected with the degenerated motor neurones 
of the brain cortex above, become involved in the degener- 
ative process, from the higher to the next lower center, or 
from station to station, in the neuraxis; that is, if the motor 
neurone or its neuraxone is so completely involved in dis- 
ease as to become degenerated or atrophied. 

[157] 




The neuraxone is practically prolonged from the neu- 
rone of the cortex till its end tufts meet and touch the den- 
drites of the lower neuraxone in the anterior horn of the 
cord. Investigations into the histogenesis of the structure 
of the cord have proved this. Degeneration may he arre stt 
here or involve only these neurones of the spinal cord, or 
may continue down the cord and outward along the 
peripheral nerve. The inflammatory nr other destructn 
action may stop at the first anterior horn or may involve 
and go on down the pyramidal tract or lateral column of the 
cord on the side opposite to the brain lesion <>r on the 
same side of the cord lesion, if the injury or disease of the 
cord be below the crossing of the fibers in the pyramids 
If the anterior horn becomes involved along with the latere 
columns in the diseased processes in antero -lateral -sclero- 
sis we have motor nerve degeneration and debility or 
tremor or paralysis, contracture, etc. Later atrophy of tt 
innervated muscles and electrical impression changes ap: 
in the muscles whose innervation is dependent on the 
affected centers. This phenomenon is called the reaction 
degeneration, and it is an almost, if not quite, unerring sign 
that the muscle tone and its innervating nerve cenUi 
integrity is lost. A like lesion of the ganglion neuronrs 
of the posterior roots of the spinal cord will similarly in- 
volve in degeneration what represents its neuraxone, the 
tropho- sensory nerve fibers so far as their distribution in 
the skin. If trophic fibers from the anterior horn are 
involved, certain skin changes result, called trophic neurosis 
or trophoneuroses of the skin. Degeneration in connection 
with disease of the posterior column nerve center neurones 
may also extend to the posterior columns in the same 
manner as that of the anterior ur antero- lateral columns 
extends downward, to the next higher nerve center, paral- 



the 

e it 

he 
he 
he 

: 
z 

ear 



159 

leling, in its manner of extending, anterior spinal cord de- 
generation. 

This degeneration may go on till it reaches the sensory 
neurones in the gray matter of the brain, but it will not 
necessarily involve them. Downward degeneration of the 
anterior and antero-lateral columns is called descending 
degeneration, and that of the posterior columns is called 
ascending degeneration. Transverse section or disease of 
the cord causes degeneration downward along the pyramidal 
or motor cord tracts and upward along the columns of Goll 
and cerebellar columns. 

The trophic centers of the sensory nerves are in the 
intervertebral ganglia of the posterior roots. Their fibers 
enter and cross the cord immediately after their entrance, to 
ascend through the posterior columns to the brain. This is 
the deep decussation. The inner column or columns of 
Goll are made up of long bundles of fibers. The outer 
columns are shorter, running to the gfay posterior horns 
and make up the column of Burdach. 

Long bundles of fibers also go up to the cerebellum in 
the lateral columns of the cord on either side. In trau- 
matic transverse injury to the cord these long and short 
bundles of ascending fibers that make up respectively GolPs 
and Burdach's columns degenerate upward from the injury. 
Long bundles in the lateral columns also pass upward to 
the cerebellum and help to make the cerebellar tract. 

Traumatic or disease lesion of the neurones and col- 
umns of one side of the cord below the crossing of the 
fibers at the decussion of the pyramidal strands cause 
motor paralysis on the side of the lesion or injury and 
anaesthesia of the opposite side and also a circumscribed 
encircling band or bands of anaesthesia around the body on 
a line or slightly below the damaged spot in the cord ac- 
cording to the distance below at which the sensory nerves 



160 



zrord 
the 



from the injured cord center or segment involved, pass into 
cord. (Brown-Sequard*s paralysis.) See Gower's spinal - 
segment and nerve exit and Brissand's schemata for illustra- 
of Brown -Sequard crossed cord paralysis at end of cl 
Ascending and descending degenerations Cftl 
truest and gravest types of tropho- neurosis. 

WALLER'S LAW OF DEGENERATION OF NERVE TISS 

This extension of disease in the nervous system 
center to center, according to the direction of involi 
and of function is cafled the Wallerian law. That i= 
repeat it in another way for illustration, the cutting of 
a nerve fiber or neuraxone from its neurone or nerve 
the neurone from which the neuraxone has developed 
proliferated* causes degeneration along the course of 
neuraxone or nerve cell prolongation. Let us ! 
diagramatic illustration with a point of disease, 
neurone or group of neurones in a motor center of 
cortex and follow it downward and out of the cord . 
involves section after section in the projection fibers of 
motor tract within and without the brain. This le ,on ' 

starting with a neurone up there in the cortex passes a ' on & 
the neurone's neuraxone to the dendrites of other nem* - "" nes 
and is there sent down through other neurones going in ^y 
means of their dendrites and out at their neuraxones. p'^rrrom 
cortex, for instance, down the corona taJiata, internal cz^^P' 
sule, and crus cerebri of either side through the pyrarn i 
decussation of the medulla into the opposite lateral coltJ mnn 
and thence to peripheral distribution. A small number of 
fibers pass down directly and escape decussation. There ^» P' 
pear to be more direct fibers in some neuraxes or ceret>W°~ 
spinal axes than in others, but not enough to vitiate the ar» a* 
tomical rule and the consequent physiological law of crossed 
motor action from right or left side of brain to opposite side of 



161 

spinal column in health and the Wallerian law of descending 
degeneration from cerebrum or cerebellum to cord in degen- 
erating spinal cord disease, or cord center to peripheral 
motor nerve in peripheral descending degeneration. 

The neurones of the motor area of the cerebral cortex 
contain the trophic centers of their neuraxones. These 
neurones appear to form, with the pyramidal tract fibers, 
nerve units, just as a psychic neurone and neuraxone 
does in the gray cortex of the brain. Cut off the neuraxone 
or axis-cylinder process from the neurone and the neuraxone 
or fiber that goes down the cord atrophies and dies as in 
the accompanying illustration. Central brain disease, 
destroying the neurone life and causing it to atrophy and 
die, causes atrophy and death in the projection connecting 
fibers and connected neurones below it. This is called 
descending degeneration. 

Ordinarily the degeneration is irreparable, but not 
always. The central neurones of the corpus striatum, the 
P°ns, the cerebellum or the medulla may suffer, (exception- 
ally only), from external pressure as in neighboring extra- 
vasation, gummata, etc., which may be removable and the 
neurone degeneration may be arrested and recovery may 
follow. (Adneural disease.) Incurable transverse myelitis 
(inter-neural disease), may cause incurable degeneration of 
the pyramidal tracts below the lesion; or a removable ad- 
v entitia may oppress the cord but be removed by specific 
treatment and electricity and the descending degeneration 
may be arrested. (Extra-neural disease also.) 

The law of Waller briefly stated is that the motor 
conducting paths degenerate downward while the sensory 
paths degenerate upward, and while this law is "not abso- 
lute and may be shattered" as Mayer, who has so ably 
translated Oppenheim, says, it is a good general law, and 
its understanding will aid you in prognosis. 



162 

In many matters in neurology we stand yet, as Edinger 
has somewhere so well said, "in the current of changing 
opinions, receiving daily new contributions." The myelin 
sheath of the neuraxone or axis-cylinder process of a cen- 
tral neurone and of a peripheral nerve is formed from many 
cells, which have an independent though common epiblastic 
origin and conditions of central irritation going to periphery 
may modify or arrest central control degenerative influence, 
such as persistent well regulated exercise in the thera- 
peutics of locomotor ataxia; the exercise connected with 
the dorsal decubitus nerve -stretching, and bathing, swim- 
ming in warm sulphur water pools, which latter 1 especially 
recommend in this formidable disease of posterior columns 
of the cord. The exercise treatment of tabetic ataxia by 
Frenkel, of "Friehof" Sanatorium, in Heiden, Switzerland, 
trains the central, through peripheral impression neurones, 
though this author does not appear to see the subject in 
this light, for he rejects both the center and the sensory 
theories of locomotor ataxia. 

Section of a nerve causes the death of its axis-cylinder. 
The axis-cylinder of a nerve seems in health to modify and 
regulate the nutrition of its surrounding myeline cells, main- 
taining their activity in a certain normal way and promoting 
or keeping up the fatty metabolisms of the myeline cells 
and regulating the growth of protoplasm. On the death of 
the axis -cylinder of a nerve the myeline cells suddenly 
increase for a time in size and activity, and then exhaust and 
shrink and become atrophied and degenerate. A peripheral 
nerve loses its irritability in man completely within forty- 
eight hours after section and its conductivity immediately, from 
center to circumference and vice versa. I could tell you much 
more on this subject than you could now receive, if we had 
the time, and more than you might now in the rush of this 



163 

course fully comprehend. When you have leisure for it, 
consult Obersteiner on neurohistogeny and secondary 
degeneration, or Barker, His, and other authors on this inter- 
esting subject. 

Artificially produced secondary degeneration as first 
practiced experimentally by Waller has been of great serv- 
ice to neurology and to neuriatry, enabling us to know the 
location and effects of certain diseases, for the results of 
experimental injury to a part of the nervous system are 
quite similar to those caused by destructive disease. And 
this is the reason experimental physiological science cannot 
yield to the clamor of the anti-vivi-sectionist, though it 
should be as humane and painless as possible and it ordi- 
narily is painless in most of its methods. 

Waller showed by vivisection that when an anterior 
spinal nerve root is cut the fibers below the section died 
and it could have been demonstrated in no other way. The 
distal portions of the root degenerate and the fibers which 
supply the anterior root to the compound nerve and that 
when the posterior root is cut proximately to its ganglion, 
that is between its ganglion and the nerve root origin in 
the posterior columns of the cord, all of its fibers die 
between the point of section and the cord, while all the 
fibers between the section and the ganglion, i. e., all the 
fibers distally to the section live. A small portion of fibers 
of the posterior root (not many) have trophic centers beyond 
the posterior root and external or distal to it toward the 
periphery. This accounts for the slight modification of the 
law. It is one of nature's conservative ways, such as we 
are accustomed to see so often and elsewhere, in her wise 
provision for the saving of man from total destruction; such 
as we see in some of the lesser vicarious paths of motor 
conduction down the cord, as we see in some of the com- 
paratively few strands that go down the direct anterior 
columns of the cord — the columns of Turck. 



FIG. 87. 



& 



**tt.O*V 






LV»*r OAflJk 




FIG. 88. 



FIG. 89. 




-Ascending *n:> 
Descending Dkiinfk- 

ATION IN THE SPINAL 

Corp. ^4, prin.irva'-ei 
of degeneration (lesion >. 
P. defeneration of toll's 
columns (ascending). C, 
degeneration rf i>- ... 
crossed pyramidal tr.ict 

Hffscvn.;:r ;; j. ( \; s ,, 

GOWERS.) 







^CSS. 



SCHEMA OF GOWER'S SPINAL 
' r?D SEGMENTS AND 



FIG. 90. 



FIG, 91. 





*^*» mutual rtkallom of ln« 
J^ rubra I bodin and iplnu 
*** Ibe •egtnttiU i n t 



Wallertao d*«i mention of 
nam u-'.-< - i . r . ii„r. 

ma I ncrv* tthtr ; J I and ///, Ohrrn 
thuiriuK ill ffi-nnl d<trtt* of AMU. 
+■ ret ion ; .•*, luunlnumit j w. medul- 
lary ahfnth ; j4, azotic ; 1, nucleus 
*>( BMrtttnm c 1! ; L, isntrkiti* of 
Lantermann ', fi. undo of Rai 
ml, drop* of myelin - a, remain* of 
axnnr; m, pruilferatijijF «dU of 
u< imlr-iDmn, PartlT .'-hematic 
^ftec Thorn*, j ^ (SLjfc^* 



&#, 



CHAPTER XV. 

THE REACTION OF DEGENERATION AND ITS USE IN DIAGNOSIS. HOW TO 
DISCOVER IT. APPLICABLE CASES. 



We have seen how peripheral motor nerves and motor 
conducting nerve paths in the neuraxis degenerate when 
separated from their proper centers — their trophic (rpo^T— 
nutrition) or nutritional centers, so closely connected with motor 
centers that motor center disease, (and motor centers and tro- 
phic centers are near neighbors in the cord), often causes 
decay of nutrition and also peripheral inaction as in mus- 
cular debility from lack of muscular exercise. Well, when 
the cerebro-spinal centers of motion are gravely diseased 
or injured so as to cause central destruction or solution of 
continuity in the cells of the central or peripheral nerve 
mechanism, of course conductivity of willed impulses is 
impossible, the neighboring trophic centers often become 
likewise involved and a corresponding change in the nor- 
mal response of nerve supplied muscle appears on applica- 
tion of electrical tests. This was named by Professor Erb, 
of Heidelberg, who first described it, the reaction of degen- 
eration. It is a nerve muscle degeneration reaction to ordi- 
nary electrical impression characterized by these peculiari- 
ties, viz: 

Muscular contractility diminishes for both the faradic and 
galvanic currents when neuro-muscular degeneration exists. 

After about two weeks from the beginning of the 

[164] 



165 

degenerative process, the effected muscle ceases to respond 
to tilie will or direct electrical current. 

The direct faradic current irritability of the muscle 
diminishes and then disappears. The galvanic irritability 
disappears also. 

Responsiveness or irritability to electrical excitation 
r ^tvirns again after a time for the galvanic current, the muscu- 
lar contractions occurring from a very weak current, but 
witH a peculiar deliberation of movement not to be seen in any 
otHer muscular contraction under electric excitation. It is 
w hat might well be called the retreating wave of neuro- 
muscular degeneracy. It is like the secondary retreating wave 
that follows from the shallow shore back to the sea after the 
Sreat sea waves have spent themselves on the strand. 

These electro- neuro- muscular waves are sluggish, 
slow. Jong drawn out muscular contractions which suggest 
ex Piringor spent power. They are singular and suggestive 
°* Exhaustion, reminding one of the protest of weakness in 
a hopeless struggle. And so they are. 

In contrast, normal neuro-muscular contraction under 

stimulus of certain faradic currents are short, quick, 

at>r upt and vigorous. The same intensity of galvanism 

^ gives the peculiar degeneration contraction would not 

c °ntract the healthy muscle at all. 

"The electrical formula is changed, /. e., the polar reac- 
l ° n s alter in sequence, and muscular contractions are changed 
11 Contrast with ordinary muscular reactions under electric- 
^- The cathodal (carbon, positive pole) closing con- 
a ' c: tion of the reaction of degeneration takes place under 
same or under a weaker current than cathodal closing 



the 



the 



^ l *"*c, negative pole) contraction. A cathodal closing 

*^tius like contraction and the anodal opening contraction 

^^^ar as the same. This is a change in electrical con- 



traction compared with healthy electrical excitatio *~» a 
change in the formula, in the language of electro-diagn«^* sis. 

If the nervous disease is above the trophic cente t~ in 
the neuraxis which innervates the nerve going to the su f^ *^ y 
of the muscle we are examining, the paralyzed muscle , as 

for instance in apoplectic disease of the brain, there <^»^ irl " 
be no reaction of degeneration, unless secondary degen^" " r ^" 
tive change sets in as a chronic sequence, which is rar*?~~ - 

In accordance with Waller's law the disease deseed 
down to the trophic centers of the cord and implicates tt' 
in destruction. That is, if a degenerative lesion, for 
ample, attacks the cms cerebri of either side of the brai 
passes down the antero-lateral pyramidal tracts, (follov*/' 
the projection tracts which we have been talking aboi~ J 
to the tropho- motor centers of the cord and destroys ] 
them, then degenerative muscular atrophy appears and vV 
this destruction of the motor and trophic cord cen* 1 
appears Erb's characteristic reaction of degeneration 
electrical stimuli. 

You must carry in your mind a little electrical knot 
edge in order to intelligently apply the diagnostic test f 
the reaction of degeneration, which we might more del 
nitely call the galvanic electric reaction degenerative chan£* 
For this is what it is. Its peculiarly slow contraction 
galvanism is the chief characteristic of the reaction 
degeneration and to very feeble galvanic currents. 

The current goes from anode (that is the plus or positive 
carbon pole) to cathode (that is the negative or zinc pole^ 
always. The positive pole must be a diffuse, wet sponge^ 
chamois or cloth electrode. The negative pole should b^ 
a smaller sponge or metal point, disc or brush electrode^ 
But always applied to a moist surface. Both electrode 
or the skin should be wet. The cathode is the negative 




167 

pole or electrode. The anode is the positive pole electrode. 
Contractions occur on opening, closing or suddenly altering 
the strength of the electric current. The effects of the 
current are uniform on all healthy muscles. Effects are 
variable where muscular innervation is diseased; /. e. t im- 
paired or destroyed. 

The faradic current is a succession of rapid interrup- 
tions. To produce contractions the galvanic current must 
be interrupted with an interrupter to break the current, 
located in the handle of the electrode or on the battery, 
or tlie current otherwise broken or suddenly changed. 

(Those of you who use the little book of Seifert and 
Mul| er f or reference must fix in your mind well the German 
W0 *~cJs, Oeffnung, meaning opening, symbol O; Schliesing, 
me **ning closing, symbol S; and Zuckung for contraction 
ancl they are not pronounced as they are spoiled, either. 
Th^ first is pronounced effnunk, the second sleezing and 
the? third zookoonk or else I am no philologist, which is 
P rc >fc>ably the fact,) Thus you have C. C. C, A. C. C, A. 
O- C., C. O. C, in health. In reaction of degeneration the 
for rriuia f contraction would be like this: A. C. C, C.C. 
C- , CO. C, A. O. C, English formula. Compare them. 
The reaction of degeneration is electrically revealed in 
destructive peripheral nerve lesion, like rheumatic, plumbic 
diphtheritic, cerebro-spinal meningitic, syphilitic and alcoholic 
paralysis, with destructive neuritides and in poliomyelitis 
anterior, where the gray anterior cornua are destroyed by 
inflammation and in transverse myelitis, amyotrophic lateral 
sclerosis, progressive muscular atrophy, bulbar paralysis. In 
brain paralysis not involving lower trophic centers, as we 
have said, when discussing descending Wallerian degenera- 
tion, we do not find the reaction of degeneration sign. 

Continuing fibrillary contractions, such as those of pro- 



168 

gressive muscular atrophy, often appears in the muscles that 
show the phenomenon of reaction of degeneration. The 
neuro- muscular action change in athetosis and tremor being 
caused by defective innervation, is somewhat akin to some 
phases of muscular reaction in partial reaction of degeneration. 
In some cases of central nerve degeneration you may have 
hyper-excitability to direct galvanic irritation of muscles, 
anodal closure contraction, then cathodal closure contraction 
and always, if real reaction of degeneration be present, 
the peculiar characteristic deliberate contraction already re - 
ferred to. 

As galvano-muscular irritability and the peculiar reac- 
tion of degeneration disappear entirely in a few months 
after degenerative motor nerve disease appears, the sign of 
reaction of degeneration is not of diagnostic value in very 
chronic cases. 

Muscular tissue in its normal condition of healthy 
moisture, is itself a good conductor of electricity and even 
dead muscles, as in Galvani's celebrated laboratory discovery 
and subsequent experiments have amply proven, so that 
something more than loss of nerve conductivity takes place 
where the reaction of degeneration shows and where all 
muscular contractility finally disappears, under electricity. 
The atrophied muscle itself ceases to be so good a conduc- 
tor as it was before. The remaining bulk and moisture 
(oil globules, etc.,) in pseudo-hypertrophic muscular paralysis 
I in which the muscle circumference is great and power 
feeble) is perhaps the reason why the reaction of degener- 
ation does not show in this disease and the muscles do 
not correspond in normal like contraction, notwithstanding 
the persisting integrity of some of the muscular fibers. 

The chief value of the reaction of degeneration sign, is 
in helpinjz us to detect true degenerative, from the false 



169 

hysterical evanescent functional paralyses. You may have 
use for it in litigation cases before the courts. When found, 
this sign is a pretty good and positive proof, like the 
microscopic evidences of degeneration in the piece of har- 
pooned muscle taken from a progressive muscular atrophic, 
bu * t:he absence of this sign does not disprove the 
existence of real degenerative motor paralysis. The time 
for the test may have passed before you apply it. There 
ma V be conditions that supplement the change in muscular 
conc * Activity and impressibility ordinarily wrought by the 
^generative forms of paralysis. It is a proof when you 
nc * it, but not a disproof when you fail to find it. 

The estimate of the force or intensity of electricity is 
a <3^ by the number and size of the elements employed or 
y t:lie galvanometric or millimeter record. 

* 'According to Ohm's law 1=^; that is the strength of 
current or intensity (1) is in proportion to the electro- 
motive force (E, number of elements) and is in inverse 
P r °Portion to the whole amount of the resistance present 
the electric current. Now an ampere is that strength of 
Urr ent (1) which is generated by the electro- motive force 
^) of 1 volt in an electric current of resistance (W) of 1 
* lr **. An ampere then, is equal to \ ™^. One volt is equal 
° nine-tenths of the electro- motive force of a Daniel ele- 
e nt; one ohm is equal to a column of mercury 106 centi- 
liters long, and one square millimeter in section (1.06 
le nien's unit). For medical purposes, no strength of cur- 
^**t higher than twenty thousandths (milli) amperes is 
s ^d. With motor nerves superficially situated cathodal 
l °sing contraction occurs normally with currents of Vi MA 
str ength." 

The strength of the current may be varied either by 
ris ^rting many or few elements, or by means of a rheostat, 



the 



170 

by which resistance of different degrees may be in 
into the current. 

In the recent clinics you have noticed that the re 
of degeneration has not been elicited. That is becau 
cases shown have been so chronic that the time fo 
electro-muscular excitability has long since passed 
chronic myelites and progressive muscular atrophies 
exhibited. 



FIG. 92. 







CHAPTER XVI. 



HOW THE REACTION OF DEGENERATION IS DIAGNOSTICATED. 



The reaction of degeneration is elicited by electrical 
test. 

The electric impressibility to both galvanism and 
faradism diminishes and disappears after about two weeks 
from the commencement of the nerve center or nerve 
tract degenerative processes affecting the connected 
muscles which are involved atrophically in the degenerative 
process. Conductivity to both the current and will, are 
lost simultaneously. 

The first thing to note is that direct irritability in the 
muscles lessens and finally disappears for a time. 

The next thing to note is that the muscular irritability 
reappears to galvanism in about fourteen days. 

The next thing to note is that the very weakest gal- 
vanic currents cause contractions and finally it is to be 
noted that the resulting contractions are peculiarly slow, 
feeble and very deliberate. 

The sensori motor nervous system now seems dead in 
its responses to faradic impression and to feebly stammer 
in its responses to galvanic electricity. If it could speak 
it would only slowly stutter in speech. 

The voluntary muscles supplied by the sensory 
motor nervous system are therefore peculiarly changed in 

[1711 



172 

fesponsive reactions to electric excitability in the morbid 
nervous phenomena called the reaction of degeneration. 

This much you need absolutely to know in general in 
order to assure yourself that reaction of degeneration is 
present in a' given case. 

But there is a farther test in the changed electric for- 
mulary. 

The normal muscular reactions to indirect electricity 
(gradually increasing the intensity of the current) are as 
follows: 

j. Cathodal (negative) closing contraction, C. C. C. 
(or in the (ierman formula Ka. O. Z.). 

b. Anodal (positive) opening contraction, A. O. C. 
or (An. O. Z.). 

c. Anodal (positive) closing contraction. A. C. C. or 
An. S. Z. 

d. Cathodal closing tetanic, (longer continued) contrac- 
tion. C. C. T. (Ka. S. Z.) lasting through contraction. 

Cathodal closing. C. C. or (Ka. S.) and finally 
cathodal opening contraction. C. O. C. or Ka. O. 

This is the law of response to healthy indirect elec- 
trical irritation of the nerves as shown through the action 
of the muscular system. It may be likened to a man in 
see-saw movement of the muscles and reads C. C. C; 
A. O. C; A. C. C; C. C. C. (tetanic). 

On the contrary in the reaction of degeneration the 
formula of contraction is changed to read thus: A. C. C. 
(An. S. Z.) f takes place with the same current as the 
C. C. C. (Ka. S. Z.), or a current of less strength and 
the C. O. C. (Ka. O. /.), shows the same as the 
A. O. C. (An. O. Z.), that is the anodal closing con- 
traction and the cathodal dosing cniitiaction give the same 
result and the cathodal opining and the anodal opening 
contractions show the same. 



In a month or so gal vano- muscular instability dimin- 
ishes and by three months has usually disappeared entirely 
not to return again ordinarily. 

Should recovery take place (which is exceptional) 
electric irritability returns tardily to the normal reaction 
display. 

Trophic central and volitional influences however are 
more potent than the electric fluid to excite muscular re- 
sponse when the degenerative processes are replaced by 
^constructive regeneration. Muscular tones and voluntary 
Motion then reappear markedly, while normal electrical 
faction comes back to the affected muscle slowly. 

\JVhen the reaction of degeneration is modified in de- 
gree^ jt j s called partial reaction of degeneration and shows 
wat -fc:h e motor center or motor conduction paths are not 
corri I> lately destroyed. Some of the neurones of the center 
and some of the nerve fibers remain intact. In such case 
nerv ^^>us irritability to both faradism and galvanism permit, 

1 *** ^ currents are applied directly and contractility is the 
result 

XJVe sometimes have partial reactions of degeneration 

^ incomplete lesions of the peripheral nervous system, 
as — ■ 

* u alcoholic, rheumatic, diphtheritic, spinal meningitis, 

^*~ippe or other neurotoxic conditions and from hystero- 

^^CDtic influences. 

Sometimes these toxic adneural influences are power- 
ful 

Enough and destructive enough to destroy reaction of 

*^^neration altogether but they do not do this so often or 

c «>mpletely as the inter-neural organic changes. Com- 

^^^ peripheral traumatisms also cause reaction of degen- 

Cr **io„. 

But the most usual conditions causing complete reac- 

0r * of degeneration are poliomyelitis, anterior infantilis or 



174 

other involvement of the gray matter of the anterior horns 
of the spinal cord and transverse myelitis or other dis- 
eases implicating the spinal cord clear across in destruc- 
tion. When the gray nuclei of the medulla are destroyed 
by extensive plumbism we may have complete the reac- 
tion of degeneration in lead paralysis. We find this 
reaction often in particular muscles in progressive muscular 
atrophy and sometimes in bulbar paralysis, amyotrophic 
lateral sclerosis and other nerve-center diseases. 

WHEN THE REACTION OF DEGENERATION MAY PERSIST 
WITH NERVE-CENTER DISEASE. 

Whenever the entire nerve center connection is or its 
peripheral nerve connections are almost entirely destroyed 
we may have this peculiar reaction. 

When the higher centers of the neuraxis above the 
medulla are destroyed we do not have the reaction of de- 
generation unless the disease descends down the cord and 
involved its centers and tracts (descending degeneration.). 

The reaction of degeneration is therefore not present 
in recent apoplexies causing brain hemiplegias or in those 
exceptional basal brain apoplexias which cause paraplegia. 

In plain local myopathic paralysis you would not be 
apt to find reaction of degeneration. 

The spinal cord center must be involved in destructive 
disease to give reaction of degeneration to muscles innerv- 
ated from that particular center of the cord. 

Degenerative atrophy of muscles is associated with 
trophic atrophy — the two go together — the atrophy giving 
the reaction is the atrophy of degeneration. 

Atrophy from central disease does not necessarily give 
reaction of degeneration. 



175 

Feeble fibrillary contractions appear in muscular areas 
Innervated by degenerated nerve centers showing re- 
action of degeneration. 

They are characteristic of progressive muscular atrophy. 

Limited central cor J disease or disease of rts circum- 
ference not involving the gray cornua as aneurism, embolism 
or tumor, does not give reaction of degeneration. 

>lute and entire destruction of all nerve fibers and 
nerve center neurones do not take place in such palsie 
show reaction of degeneration until after all reaction 
phenorm ppear entirely, after the second or third 

month. A solitary central neurone or so and a few con- 
ducting nerve fibers must remain, with some functioning 
form to show even the feeble response of the phenomenon 
of the reaction of degeneration. 

A muscle undergoing atrophy from degeneration of its 
nerve center or connecting peripheral nerve, ceases to re- 
spond to the different forms of electricity in the following 
order, viz.: first to static electricity, then to faradic, then 
to the Interrupted galvanic and finally t<> the galvanic cur- 
rent, the voltaic alternative, that is by suddenly reversing it. 

Gentlemen — it is the vaso motor influence of the gal- 
vanic current and its precedent influence on the neurones 
upon which we rely in its therapeutic use. If it can so 
demonstrably affect the vaso motor centers as to contract 
abnormally dilated arterioles through their influence and 
thus physiologically regulate blood supply and promote 
normal neurone nutrition by overcoming abnormal blood 
pressure we ntt-d not invoke a hypothetical catalytic action 
to justify the employment of constant galvanism in all 
hypera?mic states of nerve centers that may be impressed 
through the vaso motor system and its constrictor fibers. 

Erb in his M Handbuch der Electrotherapie" doubts 




176 

this, and he is a great German neurologist of repute. He 
doubted it twenty years ago but so did others. 1 was 
then demonstrating the contrary and so, I think, were La- 
borde and Latournian. 

Erb employed a large head electrode covered with a sponge 
like the one shown in the cut of your text-books, but an ordi- 
nary wet sponge electrode the anode or positive pole to the 
forehead and the negative to the nape of the neck will 
answer. He passed weak currents through the head with- 
out break from one to two minutes. One minute is ordi- 
narily enough. When you take off the current take it off 
very gradually so as not to cause vertigo by sudden with- 
drawal and filling of the contracted blood vessels. You would 
not suddenly take off the abdominal bandage after tapping 
for dropsy. The oblique currents are preferable. That is, 
from right or left forehead to center of neck behind. 1 do not 
advise the transverse currents, i. e . from temple to temple. 

1 must caution you while you search for the reaction 
of degeneration or for evidence of that advanced chronic 
degeneration which has passed all reaction stage and shows 
no response in kind or quality to electricity, that con- 
ductivity in the dry skin is nil, or resistance as the elec- 
tricians say is extreme, so that you must thoroughly 
moisten the epidermis, (with warm water preferably). You 
must also keep the current on a long time, and closed, 
and without changing the number of elements, before giv- 
ing up the test. Sometimes currents which are not felt in 
the beginning finally, if applied this way, break down re- 
sistance in the skin and cause contraction and even pain. 
Apply the current long enough to feel assured that the 
skin is wet through and permeated with it. If you reach 
the superficial motor nerves with your moist electrodes 
cathodal closing contraction ought to occur normally with 



177 

currents of from one to three milleampere meter strength. 
Be not too hasty to conclude that there is no reaction. 
Make the test thorough before deciding. A current may 
not be felt at first and yet by constant and persistent ap- 
plication its intensity increases and its effect is seen and 
felt. 




CHAPTER XVII. 

ANOTHER VIEW OF THE REACTION OF DEGENERATION. 



Objection has been raised to the views presented in 
the preceding lecture, which I here give from the best and 
most eminent source, together with my views thereon. 
Barker, who sustains his statements with excellent con- 
firm itory illustrations, in discussing the other side, after 
presenting the current conception of Waller and his fol- 
lowers, says: 

11 The application of the Wallerian doctrine has aided 
immensely in unraveling the complicated relations existing 
inside the central nervous system. Thus, in a transverse 
lesion of the cord, for the bands of fibres which degenerate 
in sections above the site of the injury, the 'trophic 
centers,' i. t\, their cells (of origin) are to be sought below 
this level, and vice versa, the cells of origin for tracts which 
degenerate in sections below the level of injury must be 
situated somewhere above this level. 

"Since the time of Waller and Turck the histology of 
the degeneration of nerve fibres after separation fiom their 
cells of origin has been studied by many — notably by Ran- 
vier, Homen (of Helsingfors), Howell and Huber, and Tooth. 
The last, in the interesting Gulstonian Lectures for 1889, 
has reviewed succinctly the facts up to that date. The 
studies of von Notthatt are of especial value, in that they 

[178] 



have yielded definite information concerning the state of 
nerve fibres at various periods after the lesion. This in- 
vestigator divides the changes which occur in a nerve after 
section into two stages. The first stage includes those 
which occur during the first three days. These alterations, 
which consist in fragmentation of the myelin and of the 
axone in the first one or two internodes on each side of 
the lesion, are, Notthaft believes, the direct result of the 
trauma. The true Wallerian degeneration (or the second 
stage) begins on the second or third day in the fibre distal 
to the lesion, and is the result of severance of connection 
with the central end, and not the direct result of the 
trauma. The axone swells and fragments, and the myelin 
breaks up into droplets along the whole length of the 
nerve. Multiplication of the nuclei of the neurilemma is ev- 
ident at the fourth day. At the sixth or seventh day 
liquefaction of the myelin commences, and this continues 
until the sixtieth or eightieth day, by which time all the 
m yelin has been liquefied and a large part of it has been 
absorbed. After three or four months the myelin has en- 
tirely disappeared. 

"During the secondary degeneration of the white fibres 
V| thin the central nervous system there is a proliferation 
°* the neuroglia. The multiplication of the neuroglia cells 
° e fcins in the white matter, according to Ceni, some forty - 
Ve or fifty days after the lesion. The neuroglia cells 
Ce ase to multiply at about the hundredth day, after which 
Ule re is a gradual disappearance of neuroglia nuclei with 
^dually progressing sclerotic change. 

f Owing to the shortness of the dendrites (unless we 

°°k up 0n the peripheral sensory fibre as a dendrite), we 

Assess no exact studies concerning their fate when sev- 

re d from the cell bodies of the neurones to which they be- 



180 

long, but we have every reason to believe that they would 
undergo speedy and complete degeneration." 

Barker then views and discusses another aspect of this 
interesting subject. Viewing now the question from the 
other side, he says: "The study of portions of the nervous 
systems from individuals who had died, a certain length of 
time after amputation of an extremity, soon afforded data 
which apparently stood in direct contradiction to the doc- 
trine of the trophic centres as formulated by Waller. For, 
while Waller demonstrated the complete degeneration of the 
portion of the nerve fibre disconnected with the trophic cen- 
tre, he maintained the integrity of that portion of the fibre 
left in connection with it. 

"As early as 1829 Berard had noticed that in the 
spinal nerves supplying a limb amputated some time be- 
fore, there was, at autopsy, distinct atrophy of the ventral 
roots. Vulpian, Cruveilhier, Hayem and Gilbert, Dickinson, 
Friedla»nderand Krause, Homen, Vanlair, Grigorieff, and many 
other investigators busied themselves with the subject, and 
came to conclusions which were often at variance, owing, as 
has been shown by Marinesco, to the fact that the authors 
studied and described different phases of the alterations. 
Marinesco convinced himself that after amputation of a 
limb, or after section of a peripheral nerve, there occur in 
the central part definite pathological changes, the intensity 
of which depends upon the species, and especially upon the 
age of the animal and upon the length of time intervening 
between the injury and death. The younger the individual 
at the time of amputation and the longer the time elapsing 
between the operation and death, the more marked are the 
alterations. The degeneration in the central stump of the 
divided nerve, although it appears much later than 
that in the distal portion, presents similar morpho- 



181 

logical appearances and is apparently an analogous 
process, although" — and herein, thinks Barker, lies the 
vulnerable point of the Wallerian doctrine — "the central end 
still maintains its continuity with the 'trophic centre.' 
Not only do the sensory fibres distal from the .spinal 
ganglia degenerate, but after a time large numbers of fibers 
in the dorsal roots proximal to the ganglia and their cor- 
responding fibres with their collaterals and terminals in the 
dorsal funiculi of the cord undergo pathological changes and 
totally disappear. The motor fibres of the central stump 
gradually diminish in number; in some instances they ap- 
pear to vanish almost totally, and a large number of the 
motor cells of the ventral horns dwindle in size and may 
after a time be actually lost. The spinal ganglion 
cells do not show gross alterations for some time after both 
peripheral or distal fibres have degenerated (Friedlander and 
Krause, Homeri, Vanlair, Mannesco), a finding which denotes 
that their trophic mechanisms differ in some way from 
those which are concerned in the nutrition of the cells of 
the ventml horns. 1 have thought that this may depend 
upon the possession by the spinal ganglion cells of a cel- 
lular capsule," concludes Barker. 

Another point is to be remembered, he thinks, in ex- 
plaining "the difference in effect of division upon the peri- 
pheral motor and sensory nerves is the fact that, if current 
ideas of conduction are correct, on section of a motor fibre, 
it is perhaps the discharge of impulses which is prevented, 
while in the case of the sensory fibre it is at first the re- 
ception of impulses which is interfered with. It must not 
be forgotten, however, that even when a peripheral sensory 
nerve has been cut through, the corresponding cells in the 
spinal ganglia may yet perhaps leceive some centripetal im- 
pulses from the viscera through the rami communicanUs." 



182 

The life prolonged of the central neurones with peri- 
pheral sensory connections depends, in great measure, on 
the continuance of normal peripheral function, sending up to 
these centers those normal irritations which keep up the cen- 
tral neurone life— "uibt irritatio ibi fluxus nutrieus." With- 
out this healthy excitation which conditions healthy neurone 
nutrition and permits and causes neuratony and neuratrophy 
to set in, the nerve center must degenerate. This seems to 
me to be a more rational explanation than the conjectural 
possession of a spinal ganglion cellular capsule. 

It would be interesting to note, as this author says fur- 
ther on the subject, "that if the sympathetic ganglion cells, 
which are also encapsulated, act similarly and preserve their 
gross integrity after section of the nerve fibres belonging to 
them." He refers to gross integrity alone, inasmuch as 
there is much evidence, some of very recent date, from 
which we are compelled to believe, he says, "that the finer 
structure of the nerve cell is always altered by the 
cutting through of its axone." 



CHAPTER XVIII. 

THE EVOLUTION OF THE NEURAXIS. 



Nature's building of the brain and spinal cord. 

* ^m not the first teacher in a medical school to make 

e °t>servation that the study of anatomy and physiology of 

t^rain, spinal cord, and connected nervous system is not 

. n ^ r *llly pursued with that intensity of interest which its 

Portance deserves, by the majority of medical students. 

Ic *^nts of medicine seem inclined to ignore the minute 

lc *V of the neuraxis, as many of them also seek to avoid 
a ^ 

rr| Uch as they can, the details of chemical and biological 

. u ^y, but the successful treatment of the nervous system 

„ ^^nds of them a thorough knowledge of the exact rela- 

^^ between nervous function and structure in health for 

J^^r comparison with the changed nervous manifestations 
of _». 

disease. Beginning with the brain, that great English 

^ r Vpheus of modern histological cerebro anatomy, Samuel 

*V, who, following Tiedemann, the great German Vesalius 
of *^ 

^^uro-anatomy, in his day, also sought to impress upon the 

^^ical world many years ago, when biology was yet young, 

. ^ "^act that the only philosophical method of simplifying and 

lr *g interest to the anatomy of the human brain, is by 

rri Hiencing with the structure and functions of a nervous 

s *^m in the lowest and simplest forms of animal exist- 

[183] 



z 



184 

ence, and from this rise by degrees to the highest, C 

fully observing each addition or part and the relationship 
borne by these to an addition of function. "By pursmn 
this course we shall be rewarded by finding that the en 
kepalon,' 1 Solly said, "this apparently most complicated organ 
in the human being, is but a gradual development from 
extremely simple fundamental type on one uniform and 
harmonious plan and that the seeming complexity of the 
cerebrospinal axis in man really arises from the great 
concentration, as opposed to extreme diffusion of its com- 
ponent parts in the lower order of animals; for in no par- 
ticular are the higher orders more strikingly distinguished 
foOOl the lower than in concentration of function within 
circumscribed spaces. 1 * As we proceed in our studies we 
shall, by the aid of this early master cerebro-anatomist 
and the help ot other and later eminent teachers, see how 
important it is to look below us in the animal scale in 
order to clearly comprehend man at the top. 

The study of comparative embryology in this way has 
not only contributed largely to our knowledge of the cerebro- 
spinal axis, but the highest interest of embryology centers 
in the light which this study has thrown on the natim 
evolution of the entire human nervous system, in which 
this chair as teacher, and you as learners, are so intently 
and specially interested. 

As the chief aim of your life will be to care for the 
brain, spinal cord and allied peripheral system , including 
the sympathetic and the organs of the body governed by 
and influencing this nervous system, it is proper that 
you should have, Lit least, an outline idea of its embryonic 
birth and development* By knowing something of its I 
lution you will be better qualified to delay or prevent that 
premature involution which morbid processes tend to bring 



ha 



185 

about and may be, to delay the ordinary involution of age 
and promote longevity. 

The human embryonic nervous system starts its 
life from a small beginning, a protoplasmic vesicle 
born of the union of an ovum and a spermatozoon. In 
the beginning a spot of protoplasm merging into a streak 
of epiblast called the medullary plate and developing first 
into an elongated neural tube larger at one end, (the an- 
terior) than the other, from which are evolved the different 
antero- posterior segments of the brain described by neuro- 
anatomists, and from the lower end of this tube develops 
the spinal cord. Of man's origin as the poet has said 
of man's entire life, it may be said,— his time is but "a 
moment and a point his space." 



Fid. 93. 



Celts of discus proligci us. 




Ovum, diagiammatk— /. <.«.un<Uiy mulcwli. 



— Portion of n\um 
«.Mru<liii£ a i*>ltir Itxly, 
ami ^lu'wiiij; a KpimUo 
ami iluster. llniiimr 
Mat Miru wml> tin ft uulo 
.!....;.- Lr... tlsi" i.rt.Tii 
« math tin- |>'.!.ir l*>-Ij\ 
'II..' im.iU- |--m.cku»i, 
J-.-.t.. t'.. Mi..l.. 



186 

A PROTOPLASMIC VESICLE BORN OF AN OVUM AND A SPERMATOZOON 

FIG. 94. 







—/., Primitive streak; //., primi- 
tive atretic and medullary groove; ///., 
later stage with medullary groove 
alone; V.. fint protovertebra. 



FIG. 95. 




—The epiblaet involuted to form the cental nervoaa 
■ingle layer, nlbbit (after His). A round flerm-oaU Ita 
proximal end* of two anpporting oelle. Obit WKevwer. 



The accompanying diagram, much like one of Kollman 
of Jena, which 1 have taken from MacAlister's Anatomy, 
and the embryonic sections following it, will serve to 
show us how small and simple are the beginnings of neural 
life and to cause us to marvel at the mysteriously and 
wondrously wrought nervous mechanism of man and the 
lower vertebrata. 




rhe germinal embryonic tube of the neuraxis closes 

^* *~ iorly in the process of development. It then swells 

into the three and later into four and finally into five 

■^rular centers located one after or below the other. The 



fir ^^ 

is 
efc> 



three divisions constitute the anterior, middle and pos- 
r germinal cerebral vesicles. The anterior cerebral vesicle 

^ * len soon divided by the development of the falx cer- 
* growing out of what is called the secondary vesicle of 
fore-brain, which is the beginning of the division of 
anterior cerebrum into its two hemispheres* The falx 
hri being the product of the secondary vesicle of the 
-brain does not descend into and bisect the other ves- 
^s in their evolution, but stops above the corpus callosum, 

*^al ganglia and the other more posterior and lower or 

*^^al divisions of the brain. 



188 

The cerebrum and cortex, caudate and lenticular nuclei 
(these two latter being cortex formations) with the fornix 
and corpus callosum, are developed from the secondary 
anterior cerebral vesicle. This forms the anterior or fore- 
brain, prosencephalon or telencephalon as it is variously 
termed. 

The primary cerebral vesicle (Vh) makes the tween- 
brain including the optic thalami and commissure, corpora 
albicantia and infundibulum. The secondary vesicle having 
evolved out of the primary cerebral vesicle. 

The mid-brain (and this is an unfortunately confusing 
term as distinguished from the tween-brain) is formed from 
the middle vesicle (Mh) and includes the corpora quad- 
rigemina and peduncles or crura or legs of the cerebrum. 
Mid and tween are so near alike in meaning that it might 
have been well to have included the near enough related 
parts which make up these two divisions under one com- 
mon designation viz., the quadrigeminal bodies and crura. 
The fewer and simpler these divisions the better, but as I 
did not make them 1 make no further apologies. 

The mid brain Hh., is made up of the cerebellum its 
peduncles and the pons Varolii. It is developed from the 
anterior of the two under or lower vesicles, Hh. Last of 
all comes the after brain and this is an ill chosen designa- 
tion to distinguish it from the hind brain, hind and after 
being so nearly synonymous. But it is the language of 
neuraxis embryological evolution and we must accept it as 
faithful followers of the Masters. Fortunately its meaning 
is easy to remember. The after brain is made up of the 
medulla oblongata alone and is developed from the posterior 
(Nh,) of the two under germinal cerebral vesicles. 

Brain structures are also divided into brain mantle and 
brain stein or caudex. All structures developed from the 



189 

secondary vesicle are included in the brain mantle. The 
structures formed from the remaining vesicles, excluding 
the cerebellum, constitute the brain stem or caudex. The 
mantle or cortex structure of the brain envelops the most 
of the surface of its three primary vesicles after they have 
evoluted into brain structures. Mantle and cortex meaning 
respectively covering and rind, the latter the same thing 
°nly more closely fitting. 

The germinal vesicle cavities evolute into ventricles and 
a <}ueducts or canals. Thus, that of the cavities of the sec- 
ondary forebrain evolves into the lateral ventricles, that of the 
P r *rriary forebrain (Vh) before division and the hind brain re- 
s P^ctively, furnish the third and fourth ventricles and spinal 
canal, while the mid-brain germinal vesicle cavity makes the 
ac lueduct of Silvius which connects these ventricles. Lower 
c, °W'n the germinal tube in the diagram (Mr) is the cavity 
°* the central canal. The vesicle cavities become the per- 
rri orient brain ventricles and the foramen of Monroe. 

FIG. 98. 




S^^WiT" 2£ rt,cal lonrftudlwd section of brain of human embryo of fourteen weeks. 1 « 8. 
S^* f*-? l 2* ri 2 ?v ; and Jtefcje") c » c er ** br al hemisphere : cr, corpus callosum beginning to 
liir * WiS ; '• ***£}!£ ot Manco • P' membrane over third ventricle and the pineal bo«Jy ; 
^l^vT^lMiua ; 8, third ventricle : /. olfactory bulb : ro t corpora quadrlramina ; or, crura 
Xo ^*rVmr i « and above them, aqueduct of Sylviua. still wide : c\ cerebellum, and below it the 
*-** ventricle ; pv % pons varolii ; m, medulla oblongata. 



The frogs of the bogs, the crocodiles of the Nile and 
* SSators of the Mississippi, the codfish and whales of the sea, 
^ giants and dwarfs of the jungles and forests, the lizards 



190 

and toads and reptiles of the fields and the fowls of the air as 
well as those anthropoid apes which make Darwin's con- 
necting link in animated nature with man, have helped us 
to know our brain and other portions of our neuraxis. 

Man's nervous system begins also with the outer of 
the three vesicle layers of the primitive embryo viz. — in 
the epiblast as we have said, which gives origin to the 
nervous system along with the intimately connected epi- 
dermis, with its hair, nails and glands and the mucous mem- 
branes of mouth, pharynx, anus and the perceptive surfaces 
of the special sense organs. This is also called the neuro- 
blast, nvpov, a nerve and £Auoros, a bud, because the neuroblast 
is the bud of and evolves into the nervous system. 

The mesoblast is also important as it gives rise to the 
neuroglia, the derma and connecting tissues generally, the 
serous and mucous wall linings of the bodies, cavities and 
vascular system, the non nervous internal genital system, 
the muscles, bones and bodily excretory organs. And we 
note here that a division begins with the very beginning 
of organic life. The germinal vesicles are assigned spec- 
ialties of work in the animal economy from the start and 
the evolved organs keep up the work to the finish of ex- 
istence. The mesoblast is the middle and the hypoblast the 
innermost layer of the primitive embryonic growth. 

Von Mihalkovics has given to embryological science a 
microscopic section of the brain and medulla of a chicken 
four and a half days old, which Edinger and other delineators 
of the embryonic central nervous system have reproduced. It 
shows the five brain vesicles fairly well developed, so well 
by comparison with the much further advanced human 
fa*tus, as for example that of His at about four weeks,* 
that it may be preferably used for our instruction today. 

•See Duane's Dictionary, Plate Iv. 




^^ itndinftl Recti on thmiiffn ttiehcnrtol nnombryorhitk oM^ tlam The five briln- 
beco»% tJ|m «%jf urelty clearly inuiknl In ih< r-f dl the IntcMiraln th a folit winch later on 
tteii :-i^ the pineal gland. The rpliliflimn nf the pharynx h being pushed up toward 

Miii.t lit c"^ ' T Hie' brain, and is the nrst rudiment of a portion of thcliypophysia. (After 

Ilind-'-riin riivUj+ fTqi-htiirtihtiftlCy Aftcr-tiffifti cartty. 

m^** ■*>"[>* >t i rmmi ^r fiv^rl'i * •* PwrAitoH, Curpcc* (|io(lHMRvli)ja, 

i Mi<M>raln i a Vontii hi? tihiihlt , Fore Vram cavityi 

ltfMAfritAwb/«, Jnt*r-braju cavity. ££ J v <*%**■»} 



ev ^latJons of nature in your study and work and give heed 
n to her instruction, She speaks a forceful and unerring, 
^ 0v4 £h silent language for your guidance, 

The prolongation of the spinal cord within the cranial 




192 

cavity, though classed with the brain, is called the medulla 
oblongata. It is distinguished from the cord below by its 
form and by the arrangement of its gray and white matter. 
Its form and relations give it its name, oblong medulla. 
The gray substance of the cord on each side expands into 
anterior and posterior horns, but recedes backward in the 
medulla oblongata and expands into a continuous layer 
posteriorly. The posterior columns of the spinal cord at 
the top of the cord are made up of white matter and di- 
verge into an acute angle forming the restiform bodies 
and making postero-lateral walls for the fourth ventricle 
located between them. The restiform bodies continue into 
and become a part of the inferior peduncles of the cere- 
bellum. 

In front, the medulla has two longitudinal elevations 
of white matter on each side of the median line. These 
are the anterior pyramids which are continuations of and 
bulbus-like enlargements of the anterior columns of the 
cord. At their lower portions they exhibit a decussation or 
crossing formed by oblique bundles or fibers crossing the 
median line from below upward to opposite sides. The 
right anterior pyramid fibers come from the left side of the 
cord and the left anterior pyramid fibers cross over from 
the right side of the cord. This arrangement forms the 
often spoken of and written about pyramidal decussation in 
the motor tract or pyramidal tract of the cord. 

Immediately outside each pyramid and almost adjoining 
it on either side is the elongated olive shaped olivary 
body called the corpus olivaria, consisting externally of 
white substance, but internally of a thin convoluted layer 
of gray matter, resembling in miniature the convolution of 
a hemisphere. They are centers of gray substance in 
the medulla oblongata, super -added to the rest, and not 



193 



continuous with that of the spinal cord. They have an in- 
dividuality and separate, though joined, existence, to the 
cord, like a neurone of the brain cortex. 

At the upper limit of the medulla oblongata is the 
tuber annulare, so called because it forms a ring* like pro- 
tuberance at the base of the brain, also called the pons 
Varolii because it bridges over the crura cerebri and named 
after Varolius, who discovered it Superficially it consists of 
transverse bundles of fibers passing over, in an arched 
form m from one side to another of the cerebellum. Strictly 
spea Icirig it is only fibers of the tuber annulare that con- 
stitute the "pons Varolii,' 1 but the entire tuber annulare is 
most frequently designated as the pons. 

Tl^is life in the human organism, as in all other an- 
,ma l Hfe, begins with the protoplasmic cells. The neurone 



with 



its appurtenances, the neuraxone, axone, neurite or 



axis ^^^linder process and its dendritic proliferations, is the 

un 't of human anatomy. These cells perverted in structure 

f \a nction are the foundation of pathology, the cellular 

°logy of the great Virchow. These cells undergo mul- 

,pic ^^ion and obscure complex transformation whose pre- 

Vt ^ snner of change and aggregation into organism is as 

s °rnewhat beyond the ken of science. We will not 

quir«^ more minutely into the peculiarities of individual 
cell fi 

^■^wlopment, though with all of its obscurity, it is an 

er e^ Siting phase of cytology. Hence we begin our de- 

lt> **on today with the initial organic beginnings of life, 

viz - 

titie blended ovum and spermatic vesicle, and from all 
We have seen or may see from our glimpses thus far 
c ^^tology and embryology, we have f derived instructive 
^ftrmation of the old maxim, omne vivum ex ovo. 

The teachings of Nature do not confirm the fiat of 
v» ntaneous generation. 






em 

lan 

ild 
ot 

; 



There was once upon a time a divinity student ex 
amined on the subject of creation and, when he was asked the 
question, quid est crerare? he answered, ex nihiio U 

To this the inquisitive Professor responded, ergo te Joctorem 
ftiiitimus. This was nearer to spontaneous generation thfl 
u v carries us and a medical doctor could not be ma 
that way. He was a divinity student. 

From this consideration of man's origin embryologically 
we may be prompted to ask with the poet, **Why should 
the pint t)\ mortal be proud?" for he begins in a spot 
ami a streak, a primitive streak and a medullary gr> 
"his time a moment, and a point his space." 

Mis life begins in ft microscopic germinal nucleus 
vesicle, this nucleus consisting of a homogeneous mem- 
i 1. 1 tie enclosing 1 network of protoplasm called nucleoplasm 
and this nucleoplasm is itself made up of infinitesimal pro- 
toplasmic thfetds or filaments of exceedingly complex or* 
gunisin whose composition consists of many thousands of 
molecules, inmputed at near half a million, 

Here is a drawing of the human ovum and germin 
i Macalister's Anatomy. (See second itltistl 

in this chapter*) 

I wo taint ridges called medullary folds {Lwrhiir dor- 
t) appear in front of the primitive groove, on eash side 
of the middle line. The furrow between them is called 
the medullary groove (#), and is floored by a streak of 
epiblast called the medullary plate. The medullary folds 
unite in front ol the medullary plate, at the anterior end 
ol the embryonic area and, as in the course of growth 

y gradually extend backwards, they push the prin 
groove to the hinder end of the area, where it finally di 
Appears (///)* 

\ with the formation of the primitive groove 



I 






195 



an intermediate series of embryonic cells appears between 
the epibtast and the hypoblast. 

The embryo (Figs. 96 and 97) is composed of thirty or 
forty segments, which begin to appear shortly after embry- 
onic life commences. The metameres or somites are ventral 
and dorsal. Each ventral metamere unites in the process 
of development with another ventral metamere or embryonic 
segment to form the cavities. The dorsal metameres unite 
with each other to form the other parts, viz.; the myotomes 
or muscle segments, the sclerotomes, or bone segments and 
other hard tissues, and neurotomes or nerve segments, etc. 

The segmentation of the germinal tube may be seen 
forming into metameres (commencing metamerism) and 
these metameres beginning to form myotone, sclerotone 
and neurotone in Figs. 96 and 97. 

An outline of the five primitive vesicles appears in Fig. 
96, and the metameres are seen in process of evolution. 

The notochord, CSp in Fig. 97, (vwtw, the back, plus 
X°pH string, > is the chordre spinalis, or primitive back- 
bone^ — a fibro-cellular or cartilaginous rod-like structure 
which is later developed into vertebra*, as the basis of the 
future spinal column and about which the bodies of the 
future vertebra* are formed. It is one of the earliest em- 
bryonic structures and persists throughout life in many of 
the vertebrates, which are on this account called notochordal. 
It is the embryonic canal developed from the cells of the 
mesohlast lying in close proximity, in the illustration, to 
the later evolved spinal cord. 

It is later on in the process of embryonic development, 
absorbed and replaced by spinal column which in man is 
always bony, though in some of the lower animal species it is 
cartilaginous. The soft pulpy substance which fills the 
cupped ends of the fishes' vertebra is notochord remnant." 



CHAPTER XIX. 

THE EVOLUTION OF THE BRAIN AND SPINAL CORD OR NEL'RAXIS 
(CONTINUED). 



OBERSTEINER'S DIAGRAM OF THE CEREBRAL VESICLES. 
FIG. 100. 




SVh, Secondary fore -brain ; 
Zh, 'tween-brain ; Mh, mid- 
brain ; Hk, hind-brain ; Nh, 
after-brain ; nw, longitudinal 
fissure; FM, foramen of Monro; 
MR, central canal. 

A brain and spinal cord (neuraxis) belong to all of the 
vertebrates. The fore-brain, or prosencephalon, is the largest 
part of the human brain. The relative size of this portion 
of the brain to other divisions of the brain, diminishes as 
we go down the scale of animal existence. The brain, as 

[196] 



197 


we see, is evolved from a primary medullary tube sprung from 


a primary vesicle. The prosencephalon is evolved from a 


secondary offshoot vesicle from this primary one, Meynert 


says these vesicles spring from and are "secondary sub- 


ordinate appendices of the primary vesicle/ 1 They are 


ystematieally disposed and lie on each side of the median 


axis of the primitive brain structure," 


And 1 must her- dfftW upon this and other distinguished 


investigators in cerebro-histology for illustration. The fust 


Fig, ioI. FIG. 102, 


^vrOfcxujoWic ySra*V*i* 


Hl^on tR*tcV«rTj 




v AImK j^s\ 


^4n h% 


V. Proscnceplia- Vwi/ ^"j 




Ion ff ore-feral n ; 


W» 


Vardtr hi r n). Z. 


Thalantencephalott 


{ Twecn-brain; Zwu- 


ehtnhimY F. Fura- v '*w of the Convex 


men between median Surface of a foetal 


/ml r. lateral ventri. Brain. 


Iff. Mcscnceph. V,-Frosenceph. S. 


alon {Mid-bram: Fossa Syl vi L Z. 


Mittelkirtt\> II. F p- ThaUmenceph. M. 


entephalon. (Hind- M esc nee ph. H. 


bratll Ifinfnhirn.) Epenceph. If. Met- 


N Mctcncq»1inlon. encepli. Beneath the 


(After-brain, A'athk- fronlal portion of the 


) (Reicherl.) prosencephalon lies 


the olfactory lobe. 


one is from Reichert and occupies a place on the first pa^e 


of the Masterwork on Psychiatry of Meynert. Here it is 


with his description. 


We distinguish (Fig. 101) the transition fr<5m the 


spinal cord into the after-brain (medulla oblongata); next 



198 

the hind-brain (H. cerebellum), which the roof of the fourth 
ventricle joins to the posterior wall of the ventricle of the 
after-brain. The mid-brain (M. corpora quadri^emina) forms 
the summit of this structure. A part of the prosencephala 
vesicle lies between the mid-brain and the vesicle of the 
hemisphere. The part is termed the inter- brain, and cor- 
responds to the region of the optic thalamus (Z). The 
vesicles of the hemisphere develop into the fore-brain (V). 

The second, with description, is by Meynert. 

Referring to illustration (Fig. 102), Meynert, the emi- 
nent psychiatrist of Vienna, whose treatise on psychiatry 
1 cordially commend to your further consideration, asks the 
student to note how in the fore-brain the anterior and pos- 
terior horns of the lateral ventricles open widely into the 
hollow of the primary cerebral vesicle. At this point the 
median wall of the prosencephalon encircles this opening. 
The outer wall of the prosencephalon has given rise mid- 
way to the fossa Sylvii. The inner wall closes in upon 
the cerebral ventricle. The fornix ascending from the 
cornu ammonis between S. and Z., regions corresponding to 
the corpus striatum and the thalamus opticus, constitutes 
the posterior portion of the median wall. The superior 
convex arch of the fornix is flattened down, but the de- 
scending portion of the fornix is enclosed within the front 
wall of the anterior cerebral vesicle. 

The fornix bounds the hollow separating' the fore and 
inter-brain, which cavity is rendered cleft-shaped by the 
inward growth of the thalamus, and forever after remains 
broadest at its interior end (foramen of Monro). 

The upper wall of the thalamencephalon consists 
simply of the membranous roof of the third ventricle, which 
passed to the edge of an arch-shaped constriction arising 
from the upper and anterior wall of the thalamencephalon. 



199 



This constriction represents the fimbra of the fornix. The 
middle choroid plexus of the upper wall is continued 
through the foramen Monroi into the plexus of the lateral 
ventricles. The fornix in reality limits the extent of the 
fore- brain. As soon as the septum and the corpus calhsum 
are developed, the gyrus fonncatus appears to be a limiting 
formation, or at least a secondary free margin of the cer- 
ebral cortex* The outer cerebral wall growing from the 

i Sylvii toward the median line gives rise to the 
ganglia of the prosencephalon and encroaches upon the an- 
nular opening in the median wall, and thus fills in the 
Olice cupious hollow of the ventricle. 

The prosencephalon continues to extend in a posterior 
direction at later stages of development; we find, therefore, 
on horizontal sections, that the corpus striatum and thala- 
mus opticus are juxtaposed from the outside inwardly, in- 
stead of lying one behind the other, 

The succession of the three cerebral vesicles is marked 
by several flexions on the axis of the original medullary 
tube. The cervical flexure (convex posteriorly) marks the 
transition from the spinal cord to the metencephalon; the 
frontal flexure (convex anteriorly), the transition from the 
mesencephalon, from which the parietal flexure is formed* 
The chorda dorsalis terminates in the sinus formed by the 
last-named flexure. 

Here are yet further illustrations from other students of 
neuro-embryology and cerebral evolution. 

They must constitute for us a lecture largely without 
words, giving you a mere glimpse only of this interesting 
subject for which you have now scarcely more time. They 
will show you the natural and normal conditions of brain 
birth and evolution and fuller details may be acquired when 
you have more time at your disposal. 






200 



FIG. 103. 




Outer surface of human foetal hrain at nix months, showing orijrln of principal 
Assures (after Sharpey and R. Winner). /•*. frontal lobe ; P. parietal ; O. occipital ; T. 
temporal ; a, a, n, faint appearance of several frontal convolution* ; ». «. sylvian fissure ; 
•% anterior division of same ; C. central lobe of bland of. KeU ; r. Assure of Rolando ; p* 
external |ierpendicular Assure. 

Upper surface of braiu rafter Sharpey and R. Wagner). 



FIG. 104. 







201 

The precise anatomic details and other elaborate de- 
scription are fully given in the pages of Meynert, Edinger, 
Foster, His, and other embryologists, and in your physiolo- 
gies and microscopic anatomies, but it is obvious we can 
not use them all here and now in a single hour. The 
diagrams and figures of His will especially instruct you if 
you have time to study them. 

Meynert copies from Reichert this frontal aspect of a 
foetal brain, with its germinal spots for the prosencephalon 
V, thalamencephalon Z, mesencephalon M, and meten- 
cephalon N, "to show what an insignificant part of the 
original brain mass the prosencephalon is." 

FIG. 105. 

M. 

$ 

Frontal As- 
pect of a Foetal 
Brain; afttr 
Reichert. 

V. Prosenceph- 
alon. Z Tha- 
lamencepha- 
lon. M. Mesen- 
cephalon. N 
Mesencephalon. 

Dr. Alexander Hill, Master of Downing College, Cam- 
bridge, and translator of Edinger, an indispensable book 
for your leisure hours, gives an interesting account of the 
epiblast, a small part of which we draw upon to embellish 
this lecture. Barker's chapter on the histogenic relations 
of the neurones will still further instruct and entertain you 
on the theme, of this lecture, as will also His and other 
embryological histologists. 

The portion of the epiblast which is marked in the illus- 




tration as the seat of origin of the central nervous system con- 
stitutes the floor and sides of the medullary groove. It is not 
simply a uniform plate, but the central portion, out of 
which the spinal cord will be formed, is distinct from a 
row of thickenings which lies on either side of the large 
main fossa. It is these lateral thickenings of the epiblast 
Which develop into the spinal ganglia (His), 

The medullary folds grow up until meeting in the 
mid-dorsal line, they convert the medullary groove into a 
canal. Closure occurs in the neck-region first, and spreads 
rapidly forwards over the head and more slowly backwards 
through the dorsal, lumbar, and sacral regions. The rudi- 
ments of the sensory ganglia (both cranial and spinal) are 
formed by delamination from the lateral thickenings just 
described (Beard), 



FIG. 106. 




~Tnwm*rw? taction* tUroagh » « to tcloptnjg chick, dtowfag ffct 



tYow L.J the ternary root-gaiigh* taller /iMnf),-fl«, Caagli*; rj% 
*y* liypaUcit: m.p metlalftry plate ; n, nutocbord j *rk 
Uil* ; tr. ocim*l auukl OV«t »*(«►* *\**» 




— But CA , r Chortoid *uleu*. 2FaX* caiid.. Nucleus ciudatua. Thai t 
Thahtaue. 8t, m,, Strin medulla da, /», o, p Pineal body. Co., Corpora 
quadrigemina* jPmIv., Pulvirwr. IV*, Frenulum, Lflf. fern,, Medial IcnmltcUA 
A. p. c, Anterior pedum. e gf cerebellum, if />, c, Middle peduncle of cere- 
bellum, SL «., Acouatic atrim ft r ., Corpua reatiforme 0, fwb., Cnneate 
tubercle. F. 0., Funiculus of Ooll. D> m. f., Doraal median flasure P. <ml. 
Paramedian aulcua* &, Jr., Lateral tract D I. *tit. t Dorsolateral < ulcus 
F. B. f Funieului of Bnrdach. CI,, Clara. Ah ctn n Ala cinerea. 7" k., Hypo- 
gloaaal triangle. A. a ., Acoustic area, (7, i% Colliculuf farfalii. 8. Mm., 
Sulcus limitana, E. m,, Erainentia medial is. V, P., Anterior medullary* 
velum. /T, Trochlear serve. C. p. m.„ Medial geniculate body. C. ff. t+ 
Lateral geniculate body. P. Dr., Posterior brachium of mesencephalon 
(After Vaa Gehuchten.) 



204 



THE EVOLUTION OF A NEURAXIS. 
FIG. 108. 




As delineated by Samuel Solly, the English Corypheus of modern neuro- 
anatomy. This illustration is not so clear as we should have been pleased 
to have made it, because of the tarnishing of the plate by age. The work 
is marvellous, considering the remote year in which the work was done. 



Lateral view of fully evoluted human cerebrum, showing 

CONVOLUTIONS, FISSURES AND ARTERIES. 

(After Testut.) 

FIG. 109. 




t tmr* frMtaJt i«Mrt««rt. - X vttni ftwtUW uu*4tito — i. *n*n 



205 

The sum of this matter of the embryonic evolution of 
the brain, from the three primary vesicles stated in an- 
other way, is as follows: From the anterior vesicle de- 
velops the optic nerve and its retinal- expansion or retina 
in the posterior part of the eyeball. The anterior vesicle 
then undergoes subdivision into the anterior and middle 
vesicle. From this develops the prosencephalon (fore-brain), 
from which are formed the cerebral hemispheres. Budded 
off from the prosencephalon are two lateral vesicles, 
the cavities which constitute the lateral ventricles, cor- 
pora striata, and olfactory lobes ( rhienocephalon ). "The 
floor of the thalamencephalon or diencephalon (inter-brain) 
forms the optic, chiasm and infundbulum; its walls the 
optic thalami; its roof the pineal gland, anterior and 
posterior commissures, velum interpositum, and choroid 
plexus; and its cavity the third ventricle. The floor of the 
middle vesicle (mid-brain, mesencephalon) forms the crura 
cerebri; its roof the corpora quadrigemina; and its cavity 
the acqueduct of Sylvius." The posterior vesicle divides 
into two parts, an anterior (hind-brain, or metencephalon, 
the floor of which develops into the pons and the roof 
of the cerebellum; and a posterior (after-brain) myelen- 
cephalon (Wilder) the floor and sides of which form the 
medulla, and the cavity of the fourth ventricle. {Vide 
Duane.) 



206 



ILLUSTRATION OF A PORTION OF UNDER SURFACE OF BRAIN IN IMMEDI- 
ATE CONNECTION WITH. AND CONTINUATION UPWARD FROM. THE 
SPINAL CORD. ALL THE CRANIAL NERVES ARE HERE SHOWN. AM) 
NEARLY ALL THE UPPER (CRANIAL) PART OF THE CEREBRO-SPINAI. 
AXIS. THE OPTIC NERVE DISTRIBUTORS DO NOT SHOW NOR DOh* 
ANY OF THE LEFT HALF OF BRAIN APPEAR EXCEPT THE OPTIC THAL- 
AMUS, THE LEFT CROSS CEREBRA. OPTIC TRACT, ETC., DL- 
SCRIBED UNDER THE CUT. THE ANTERIOR UNDER LOBE ON RK.HT 
APPEARS AS LIFTED AND PRESSED UP AND FATTENED SOME. 

FIG. 110. 




bt riariciAL Oiir.im 
I' UtUrttfty tr««.< 

II Upiu »»r«. 
II" Omk Iran 

III lhltd or ovulo-moioi 
Mm 

IV Knunh Mhf 

V F>llh nf nt. Mitvny f>ii 

V 4 rriiKncr** motor n>ot 
i.i.i Main A, ..».. ii. uflifih 

VI v,„Kn*r.r 
Ml F> lU |»f.«f 

VIII Ai«! tt-f > ner»« 

IX (tUnvj infinite*! 

X V. g „, 

XI Spinal I'ttMiry 



or C«a<ual Niavav t/r.m 

XII H>|w*lo»ul. 

1 1. r»r»i «.tr»t,*l n#rvc. 

C NUr.f o( Kff>l. 

IK ll|i| - iruiljitim (ih« |«- 
UnJ rf Ketl having bcvn 
rtm.)»«d . [turn 

I lnt«mtl curptrt K«ni<uU 

* r «-»rnal #«nK<jlatufii 

k Pi . i.iv kxly 

A 1 ."■*! cinrrr-'.im 

a One of Iht ior|*'.ra a|!* 
. j-.i a 

\p *»*.* jn fittur* 

i» An'i'iw perforated 



(1m/« i " Amml9my"\. 

■ PoMsnot pcriWucd 

•pat*. 
P Ir-rvbral awftuacl*. 

I'V Pv*H Varolii. 

C« OrrhrOwaa. 
/ F.lki 
* FWctikM 
/« Aticrw pyraaaMl 

J Antrnor aacdiM 6«*urc 

-rcord 
*' lateral tract •faatrf.ilLa. 
' 4 Axtcrmr rntuat*. 
( / lateral Cotuaaa. 



207 



Description of fig. 108, page 204. 



The figures in Fig. 108 represent different stages in the development of 
the human brain. The first three of this series exhibit the form of the fretal 
brain at seven weeks, with a side and a posterior view of the cerebro- 
spinal axis at that early period. 

Fig, 6 shows the amazingly rapid progress which development has 
taken at the ninth week, while Figs. 7, 8, 9, and 10 show the brain of a 
fptus of twelve weeks and point out still more decidedly this steady ad* 
vancement. 

Fig, 11, showing the brain of a foetus of fifteen weeks , teaches us how 
gradually this important organ advances towards perfection; and 12, ex- 
hibiting the brain of a foetus of nearly five months, is interesting, as it 
demonstrates that even at this advanced period the brain is still smooth 
like the brain of a rodent animal. 
Fig, 3. Foetus of seven weeks. 

a. Projection of the neck. 
Fig. 4. Brain and spinal marrow of the same foetus seen laterally. 

a. Spinal cord. 

fir Enlargement of the cord. 

t< Cerebellum, 

■/ Optic tubercles, or quadrigeminal bodies. 

#. Optic thalami, 

f. Merobranlform hemispheres of the brain, 

g. Protuberance anatagous to the corpora striatum. 

Fig. 5. Posterior view of the same brain, split and open in all its length, 
j, a. Spinal marrow. 
b< Orifice of the canal of the spinal marrow. 

welling of the spinal marrow, 
d, d. The cerebellum split in the median line, and laid like a bridge 

over the fourth ventricle, 
t. 4. The quadrigeminal bodies separated from one another In the 

median Line. 
Fig. 6. Brain of an embryo of nine weeks, 

a t a. The two principal columns of the spinal marrow, separated from 

one another by a longitudinal fissure, 
b t b. Cerebellum 

c. Parts which give rise to the quadrigeminal bodies, 

d. Thaiami optici. 
s. Membranous hemispheres, turned backwards and inwards, 



208 

Fig. 7. Brain of an embryo of twelve weeks seen in the cranium. 

a, a. Fragments removed from the cranium, which has been opened. 

b. Spinal marrow. 

r. Swelling of the spinal marrow, which is bent inwards. 

d. Cerebellum. 

f. Elevation which gives rise to the quadrigeminal bodies. 

i>. Crus cerebri, or a cord of the spinal marrow which comes down 

again and is directed forwards. 
h. AAembranous hemisphere of the cerebrum, broken down behind and 

before; it does not yet cover the eminences destined to form the 

quadrigeminal bodies. 
Fig. 8. Brain and spinal marrow of the same fa*tus seen posteriorly. 
j. j. Spinal marrow, with its posterior longitudinal fissure. 
b. Cerebellum, and beneath it the fourth ventricle, 
f, r. Hemispheres of the cerebrum, 
i/. Eminences which are to become the quadrigeminal tubercles, with 

the fissure which they present. 
Fig. W. Interior surface of the brain of the same f<rtus. 

j, a. Spinal marrow, with the anterior lorgitudinal fissure. 

b, b. Swelling of the spinal marrow bent forward. 

<-. <-. Peduncles of the cerebellum, which arise from the cerebellum. 

•/. J. Cerebellum. 

« . .-. PeJuncles of the .ertbrum. 

/. Mammillary emii.erKes. 

;'. Pituitary gland. 

//. //. Anterior 'obes of the cerebrum. 

/. /. The posterior and round appendices which represent the middle 

and posterior lobes. 
Fig. 1'.'. View of the superior surface of the brain of the same fatus; the 
membranous hemispheres are separated from one another and laid aside, 
.i. j. The two princip.il cords of the spinal marrow. 
b. Posterior longitudinal fissure. 
t\ t*. Cerebellum. 

J, ./. Masses which are to form the quadrigeminal bodies. 
«■. t. Thalami opticl. 
/. /, c C. a* *.'■ Membranous hemispheres separated from one another 

and laid on the sides. 
//, //. The two corpora striata, which are a little wider anteriorly, and 

Jivided mto. two parts bv a slight fissure. 
/. Commissure of the two hemispheres and commencement of the cor- 
pus callosum. 
/. . a. Lateral ventricles, with the radiated folds of the under-surfa:e 

of the hemisoheres. 
Fi/.. 11. superior surface ot the brain ot a f<rtus fourteen or fifteen weeks 
of age. 
.i, j. Spinal marrow. 



209 

b. Peduncles of the cerebellum separated from one another, from 
above downwards, which brings the fourth ventricle into view. 

c. The cerebellum, which has not yet any fissures. 

J, «/. The right hemisphere of the cerebrum, which does not yet cover 

the quadrigemtnal mass. 
/. Sinking of the membranous hemisphere. 
Fig. 12. Side view of the brain of a fa-tus of twenty-seven weeks. 
j. Spinal marrow. 

b. Corpus restiforme. 

c. Corpus pyramidale. 

d. Corpus olivare. 

e. Cerebellum. 

/. Bending of the spinal marrow forwards. 

si. Cerebellum. 

//. Annular protuberance. 

/. Middle lobe of the cerebrum. 

k. Posterior lobe. 

/. Anterior lobe. 

in. m. The fissure Sylvii are wry deep and extend to a great distance 
on the sides; thev lodge th»» middle cerebral arteries. 

«. The olfactory nerve, which descends from the tis*ura Sylvii. 

<», o. o. Depressions on the cerebral substance, which are a com- 
mencement of the convolutions. 



The brain ventricles, according to Walker, who made the experiment of 
displacing their fluid with ventricle casts, were found t> contain twenty-six 
cubic centimeters of cerebro-spinal fluid. You can try this experiment and 
verify Walker in the dissecting-room. After casting the ventricles, put the 
casts in fluid and measure the amount they displace. 

The gray matter of the cerebrum, according to Halliburton, 11 averages 
SI per cent and the white matter of the brain and neuraxis is 70 per cent. 
So that man's nervous system is mostly water, notwithstanding its won- 
drous construction. 

From repeated experiment Hroca concluded that the pia mater weighed, 
normally, from 45 to 50 grams at ag-.?s averaging from twenty to sixty. At 
fifty its weight was ten grams, or one-sixth less than at sixty. At from 
twenty to thirty it weighed fifteen grams less, or one-fourti the weight of 
the pia at sixty years of age. 

The records of normal brain weights include the normally tilled blood 
and lymph vessels, ventricles and membranes co:inecfed with the entire 
encephalon. 

* Howell's Text- book of Physiology. 




4mRfl«4w 









'brain 



Mm itivtiltV), unil tvnmvnl tin 



Practically the brain mantle is alt of the brain above this. 





CHAPTER XX. 

HISTORY OF THE EVOLUTION OF THE BRAIN. 
SOME FURTHER FACTS CONCERNING THE BRAIN. 

In 1819, before these plates were made, Arnold, Reich - 
ert, Foville, Burdach and others had made important 
contributions to embryologic and fully developed brain 
structure. Burdach's book on the life of the brain was 
published as early as 1819, and Reil had already, according 
to the testimony of Edinger, practiced the hardening process 
and discovered the corona radiata, the nerve course of the 
tracts of the crura cerebri and their relation to the corpus 
callosum, "the lemniscus and its origin in the corpora 
quadrigemina, the lenticular nucleus, the island of Reil and 
many other parts." 

In his first lecture Dr. Ludwig Edinger, of Frankfort- 
on-the-Main, gives an interesting resume of the advance 
of discovery and methods of study, bringing the record 
of work down to the days of Ramon y Cajal, Lenhossek, 
NissI and the other men of mark in our time in neuro- 
cytology. This is of such interest that 1 abstract the es- 
sential part of the record. 

"Up to about the middle of this century the most 
prominent methods of investigation were anatomical dissec- 
tion with the knife and teasing out fibers from hardened 
specimens of brain with forceps. By the latter method 

[211] 



212 

Gall, Burdach, Reil, F. Arnold and Foville discoveied much 
that was new. To Tiedemann and Reichert is due the chiet 
credit of introducing the studv of embryology, from which 
we have learned much concerning geneial morphological 
conditions. 

In 1833 a delineation of the brain's evolution by Sam- 
uel Solly, one time Lecturer mi Anatomy and Phvsiology in 
St. Thomas Hospital, appeared in F.ngland, based on h:s 
own and the researches ot Willie and Vieus-eiis, (the lattei 
first having demonstrated (in 1S64) the fibrous s'uhtuir of 
the medullary portion ot the brain), and th »se ot R ul, (i.iM, 
Spursheim, Vicq, d'A/.yr, Rolando, Sommering, Seires, 
Tiedemann, Sylvius. Nepp.-r and Van Leuwenhuck, the lat- 
ter having first instated micros -opical examinations ot the 
brain. 

* * About this time LhrenN-iL! proved that the 

brain consisted oi innumerable micios^opi.- "tubules." 

Remak (1SSS) had given a m-He accurate description 
of tile ganglion-. flK, and Hannover ( 1S-10) had shown their 
connection with the nei\ e- fibers. After this fcdinger states 
that "a simple process ••! te ising o>uld never give the desiitd 
insight into the structure and airangement of the central m-rv.. :» 
system. To \i. Stii'irrj K due the gu-at credit of originating 
and blinking into • !<»• t i new method, viz., the preparation 
of thin sections, or lathei, <>t whole series ot sections, which 
are male in ditteieiii '"\> i:i definite directions thiough tin- 
organ t • he e.\ : m.'.ued. In a too! not-* kdingei says: "Thin 
section «t the - - - r ■ T * i i n.-i\ous system had been made be- 
fore St:;! ■■■.:;'■ I'm- i,\ ;., U. Rolando. 1S24). but the n-c.in- 
stni.t: :i «if the "!_;'.•) hv the i oinhmatioii of extended 
selh- ■■! -■ [>>. was :;:■? ; ,-. r [. v Veiling." 

I ■■ ■ t-.'is. - . p-.-i-i'.-l wi-re carefully examined 
thiough ■ .t f th« p: i.iivs th v ptesi-nted v'»m!>ined, and thus 



213 

the structure and arrangement of the central nervous sys- 
tem were determined. By means of this method and the 
studies which he instituted by its use, Stilling laid the 
foundation of the modern anatomy of the spinal cord, the 
oblongata, the pons and the cerebellum. On the 25th of 
January, 1842, Stilling froze a piece of spinal cord at a 
temperature of 13° R., and then, with a scalpel, made a 
moderately thin cross-section. 'When 1 placed this under 
" le microscope, ' he writes, 'and, with a power of 15 diam., 
saw the beautiful transverse striations (central nerve- 
tracts), I had found a key which would reveal the mysteries 
°* the wonderful structure of the spinal cord. Not more 
J°yfully did Archimedes cry out, "Eureka!" than 1, at the 
flrs t sight of these fibers.' " 

Stilling's method was, up to within two decades ago, 
*' le one most used in investigations of the central nervous 
s ^ s tem. "It is rendered very much easier by the splendid 
hardening which these organs undergo in dilute chromic 
ae *d , or in a solution of chromic salts, — a discovery of 
^ ar *nover and Hckhardt. 

"The sections are made 'free-hand,' with a razor, or, 
e tttr, with a microtome, which cuts much more exactly 
^^1 enables us to make larger and more even sections, 
^^^lcker, Rivet, Weigert, Thoma, (iudden, Schiefl'erdecker, 
n ^ others have been of service in constructing microtomes 
^•^■pted to the purpose. We can now divide an entire 
^^"^""lan brain into an unbroken series or sections, less 
^^ti -fV millimeter in thickness. 

"These sections may be examined unstained. All that 
1 1 ling discovered was found in such unstained sections. 
is better, however, to use staining tluids. 

"To Gerlach is i\[\<- the credit ot lirst calling attention 
^•^^58) to the advantages to be derived from staining the 



214 

sections in carmine. As time passed on, many new stain- 
ing methods were devised, particularly with aniline colors 
(nigrosine, etc.). 

"But it is only very recently (1883) that we have 
learned from Golgi a method which brings out ganglion- 
cells more distinctly than the old one of Gerlach. This 
method rests on a production of a deposit of silver salts in 
the cells and their processes. The course of the fibers in 
the central nervous system is not made much more distinct 
by staining with carmine. It is possible, however, by a 
method of staining with hematoxylin imtroduced by Wei- 
gert (1884), to color even the finest nerve-fibril a deep 
blue-black, and so, making use of Stilling's method, it is 
easy to trace the course of the fibers much farther than 
was formerly possible. 

"The stained sections are, in accordance with the 
special instructions of Clark (1851), dehydrated by placing 
them in alcohol, and then cleared up in some ethereal oil 
or xylol. But unstained sections also reveal the course of 
the fibers if cleared up in xylol, as was done by Henle 
and Merkel. This, however, does not always succeed. 
Beautiful pictures may be obtained by using the gold stain- 
ing methods of (Gerlach, Flechsig, Freud, and many 
others). Also, by staining the nerve-fibers with osmic acid 
(Exner)." 

Selling's method has, up to very recently, been followed 
by most of the investigators of the latter half of the nine- 
teenth century, but has been later succeeded by the method 
of Golgi, of which you are to learn much as you advance in 
the study of microscopic neuro-anatomy. 

The revelations of brain evolution under the difficult 
and meager methods of investigation prior to the hardened 
brain slicings and the advent of the microscope were won- 






215 

derful testimonials, as some of these illustrations show, to 
the indefatigable spirit of research of our forefathers on the 
field of neural embryology. But the later sections and micro- 
scopic discoveries of brain and cord and nerve, startle cre- 
dulity and almost surpass the bounds of possible belief. 
They astonish us like the telegraph did our fathers and as 
the phonograph, graphophone, mimeograph and marconi- 
£ram surprise us, Yet their revelations are astonishingly 
true. Science now places its penetrating finger upon the 
n ^urones, whose dwelling place is at the seat of perception, 
•^■flection and psycho-motor function, as we have already 
eit t in our survey of neurological research and as we shall 
3^et see further in our progress of discovery along the pathway 
°f theneuraxis. Electrical discovery too has aided us, espec- 
f -illy in the direction of cerebral localization, which will en- 
^3ge our attention in another lecture. For by its means, 
^*Hth insulated electrodes, Fritsch and Hirtzig proved the fo- 
cal electrization of the brain and Ferrier, Horsley and fchetl 
*<^1 lowers have localized its psycho-motor functions, most of 
^hich have been confirmed by demonstration, pathological 
r>roce : associated cerebral symptoms. 

There are some general facts concerning the brain 
*^tch may profitably be recounted here, before we discuss 



th 



<? 



subject, as we shall, later on, more specifically. 



Bf *ain size and brain weights and their relation 
to mind capacity. 



The aggregate complexity of thr nervous system seems 

•Neatest in what naturalists call the primates, or man and 

t^s and the vertebrate animals. Invertebrates are consid- 

r e^d by the same authority to have no brains, and the ex- 

^P'e of tlie sanguisuga, or common leech, the house fly, 



216 

etc., are cited. The latter is an unfortunate illustration • i"f 

the lly's intelligence is revealed in various ways, ru»t t< * ■ the 
same extent as the ant and the bee, but sufficiently to i t pli- 
cate that it has an organ of limited intelligence, like the 
frog, the mosquito, etc. liven the leech, though he Uimkl *-ws 
not when to let go, knows when and- where best to hold °n, 
as 1 once discovered when 1 got into a colony of t 3 »t*rc 
while in swimming in my boyhood days. 

In man and apjs th - cerebellum is covered a bow — mJ 

in front by cerebrum. In all tin- lower animals the co-^—~ "fl- 
ing is imperfect, in man and apes the cerebrum is hi^-^ ' l '. v 
convoluted, the convolution becoming shallower and ^ t<s 

complex as we descend the scale of vertebrate and m '-'"* m " 
mal life and in imbeciles and idiots. 

The weight o^ man's brain is heaviest in prop ! :ti >r ~* *- 

body weight, ol all veitebrate animals. Man's brain i^ r-^ 11 

to average ten per cent greater in weight than w«.»ma - ""*■ 

but the new woman knows a good deal and does not be! i ^— " 

it. The average weight ot the male brain is about 4 l > *" * 

Average weight of the female brain 44 oz. Heaviest nor" *~ ""* 

male brain 65 <»/. Heaviest normal female brain 56 *" 

Lightt-st. noimai male brain ^4 oz. Lightest normal un ~* 

— — « i^ 
brain 31 o/. Lhot^ 23 oz. The composition of the hrai * 

albumen, different phosphate^, salts and water. The nor * ~* 

brain awraue-. in weight theieloiv trom 34 to 50 oz. 'f 

normal tein.ile brain ;t\v:age^ i:i weight from 31 to 44 o>< 

.Wuital lc\'h;"i -u! and p-.wi-r is said to depend, all th i ' 

hem:: eqa ii, 'ir'*:: \'\ i v and wei-jht of the brain, the c* > ^ 

ple\i!\- .I;..! .'. ■■: ■ ,!"■.- ■■ i , •. . ., ut i< »n ^ nt its gray mattei . hi * 

ne-- i te- : i ■;•■■ i i , ! !■ >w . \ « i , to do with qualitv '>! b T^- 

and 11 ■• i- ■'■■• *; ! . " \v«. .hi awa size to size ot the \x^^ 

^ >x 
wiiii • ::[• 'v. I ' •"-..!■: :':.- near<»ne of the gray cort- 

,, ■,■ i • : : ex. . ; \ ■ ] ; ; . ;• ': is been said that Bvroi' 7 



217 

hat was too small for the head of any of his contemporaries; 
Gambetta's brain was the smallest of any European states- 
man, while an American senator of ability (Dunn of Indiana) 
is said to have had the smallest head, compared with the 
heads of his colleagues (he wearing a 6!l> hat), while the 
biggest heads were owned by Benjamin F. Butler and a 
colored porter at the Capitol. Professor Waldeyer reported 
to the Prussian Academy of Sciences measurements of the 
skull of the Philosopher Leibnitz, which was discovi red a 
few years ago in repairing a church in Hanover. The cran- 
ial cavity measures 1,422 cubic centimeters, indicating a brain 
weighing 1,257 grammes, which is unusually small. 1 he 
contour of the skull shows that Leibnitz was of Slavic origin. 

Gottfried Wilhelm Leibnitz was bom in Leipsic in 1646. 
He died in 1716. He studied law and in 167N was made a 
counselor and member of the Supreme Court by the Duke 
of Biunswick- Luxemburg, but his fame was made by his 
writings on philosophical subjects. 

Dr. James Morris ivcoids -\ brain weight of 67 o/. 
belonging to a bricklayer, who could neither read nor write. 
Gambetta's brain was light weight, bring about 41 oz., 
while Byron's was heavy, being near (A oz. 

We know that the intelligence of the ant. tin- bee and 
the beaver are proverbial, while the eve i-f tha fly is vjuite 
as perfect as that ol the o\\ Mwhocepiialic .-hildre;i and 
sonu idiots have enormous heal-. The heavie-; a lu'.t male 
brain on record weighed 6S- .. n/.iNan n< ■!•■•. A h: ww \v< ■■ h- 
ing 66 oz. belonged to the craim.u. oi . : 1.. ui-vil'e Ivl-.er, 
whose chief merit in the world .;<.| : s<vt..,| j ; i his .ilv! :v t«. 
make a fairly good lo.it .»: -*:ea 1, and \\\ ■ N a : i ; .i.i < -\\ • 
leptic is recorded as weighing 64 «-z., a:- a • !" •. r. ::: 

Daniel Webster's. Cu\k;, i!:e n. ■'.■;.'■ \ '. . 1 a .■: i::i 
weight of 64.5 oz.; Ah-. :ci«>':ib:e, th-- pi- a ■. ' ".% 



2 IS 

Schiller, the poet, the same, while Agassiz, an American 
naturalist, had a brain weighing S3 oz. Gocdsir, the anato- 
mist, had a brain weight of 57.5 oz. Dupuytran's brain 
weighed but 50.7 oz.; Hughes Bennett, physician, 47 oz. t 
Hausman, the minerologist, 43.2 oz. 

Brain of an idiot (Holden's Anatomy) 23 oz. 
" " " " (Nancrede) 31 oz. 

Epilepsia and chronic insanities show high average 
brain weights, while in imbecility the general male average 
is below, the general female average is above the general 
averages for the respective sexes, according to Crowley 
Clapham's deductions from extensive research. In senility 
and in senile dementia the brain shrinks in size and loses 
in weight in both sexes. Clapham found brain shrinkage 
in general paralytics, but that was in chronic insane asylum 
cases, after the dementia stage. There is no evidence of 
loss of brain weight in the earlier stages of general paresis. 

The commissural fibers of the brain enter into the com- 
position of the corpus callosum, the anterior middle* and 
posterior commissures bridging the third ventricle. They 
compose the fornix and connect the two lateral hemi- 
spheres; they enter into the composition of the middle pe- 
duncles of the cerebellum, which in part serve to connect 
the two cerebellar hemispheres; and into the decussating 
fibers in the medulla and pons. "The longitudinal fibers and 
ganglia comprise five systems: (1) The pedal system in- 
cludes the pyramidal tract starting from the parietal cortex, 
the anterior cortical fibers from the frontal cortex, the lat- 
eral and posterior cortical fibers from the temporal and oc- 
cipital cortex, and the caudate and part of the lenticular 
nuclei with the fibers descending from them; these fibers 

•Th<* middle commissure belnK of gray matter and not strictly a commissure, though 
it K c«lled the gray commissure. 



219 



all pass through the internal capsule and pedes crura cer- 
ebri into the pons, where all terminate except the pyram- 
idal tracts, which pass down to form the anterior pyramids 
of the medulla, which are continuous with the pyramidal 
tract of the cord. (2) The tegmental system includes the 
thalami optic* with radiating fibers connecting this system 
with the cortex, the longitudinal fibers of the tegmentum of 
the crus cerebri of either side with the imbedded nuclei 
(red nucleus, substantia nigra, corpus subthalamicum), the 
tegmentum of the pons, with the locus ceruleus, fibers con- 
necting the tegmentum with the cortex, the superior pe- 
duncle of the cerebellum connecting the cerebellum with 
the tegmentum, the fillet, connecting the nucleus gracilis 
and nucleus cuneatus of the medulla with the tegmentum, 
the longitudinal posterior bundle of the pons, the brachia of 
the corpora quadrigemina and the reticular formation of the 
medulla. (3) The system of central (ventricular) gray 
matter comprises the gray matter lining the ventricles, in- 
cluding the nuclei of the cranial nerves adjoining the fourth 
ventricles and the tuber cinereum on the floor of the third 
ventricle. (4) The system of outlying cerebral ganglia 
comprises the corpora quadrigemina and the external and 
internal geniculate bodies. (5) The cerebellar system com- 
prises the nuclei of the cerebellum (corpus dentatum), 
(emboliform or wedge shaped nucleus, roof nucleus, etc.), 
with the cerebellar tracts (inferior peduncles of the cere- 
bellum or restiform bodies, connected below with the 
olivary bodies and nucleus gracilis and cuneatus, and with 
the cerebellar tract and posterior median and external pos- 
terior columns of the cord). 

Look at this brain. It is composed outside, of cin- 
ercious or gray matter, made up of basal ganglia, cortex, 
corpora quadrigemina, geniculate bodies, ependyma or lining 





220 

of the ventricles, etc., nerve cells and connecting fib *f* rs or 
communicating neurones; within its white matter is made 
up of neurones forming longitudinal and commissural f~i bers 
called medullated nerve fibers. The neurones re<r*Hve, 
store up, and manufacture nervous energy and the n terve 
fibers transmit nervous energy and nervous impulse ?> a"d 
impressions. The brain is covered by these three iT~i**n> 
branes or meninges, first, internally, the pia mater, \vh^ 
covers it closely, next the serous membrane or arachnoid 
and the external fibrous membrane or dura mater. "T* w 

arachnoid bridges over the large fissures of the brain cov- 
ering subarachnoid fissures filled with cerebro-spinal fl vU 
The ventricles of the brain are continuous with the cen tra 
canal ot the cord and the subarachnoid spaces. They" live 
lined with a layer of ependymal glial cells and filled v^ rl 
cerebro-spinal fluid. The brain is continuous witli *" 
cord, its gray matter becoming internal and its white m " 
ter becoming external. 

It is the function of the brain in its cerebral corte^^ 
receive mental impression, conduct intellection proce^- 
evolving and expressing emotion and thought. Recep* * 
ot mental impression and conscious appreciation of sensati ^~* 
are here located. They reach the cerebral cortex thr^*- *" 

the nerve nuclei, coipora quadrigemina, tegmental system-**" 

*al 
occipital and temporo- sphenoidal cortex, and the peripln ~~ 

communicating sensorv nervous svstem. The cortex of "^*-~ 

nd 

brain initiates voluntary motions, including speech, «* — 

It 

receives o'nvhuis ;ukI unconscious impressions from wit 

or 

out it. I Ins takes place in the fronto-parietal cortex 

ps\vho-mot«>r .irea and is expressed in connection with t 

— ^^^ lu 
motor nerve- and pvramid.il tract. The brain produces a^^^ 

regulate^ bodily heat (caudate nucleus, tuber cinereum). I 

medulla maintains respiration, inhibits the heart's action ai 



221 

initiates and maintains deglutition and vomiting, accelerates 
or inhibits peristalsis and the various visceral operations are 
increased or diminished by the cerebral cortex, as urination, 
defecation, etc. Complicated movements and coordinate 
movements take place through the cerebellum. 

Consult your anatomies and physiologies here and 
dictionaries and medical encyclopedias on the subject of 
brain function often in connection with this course. Much 
of this description will be found in Dunne's Dictionary. 

ANTHRO-POSTLRIOR SKGTI'>N THROI (,}| OlRIIHRl'M. 
FIG. 112. 




Showing association neurones passing from fronta to occipital lobe 
and manner of connection of pyramidal cortex ru-urones. A. C. H. a ter- 
minal axone at I), collaterals ot association axones at F, and cut ends of 
crossing corpus callosum fibers at f. i Alter Ramon y Cajal.) 

This illustration was shown farther forward in this course of lectures. 

FIG. 113. 

cx^\«.'c Wn lere. 






jn £ 







:: %£4& 



eoliths upli ; .w-. 



p,:r Irur face extern* 
w Icu'.ioul'iirc ; — <J>, 



222 

ADDENDUM. 

The London Lancet, of November 29, 1902, referring ed- 
itorially to the weight of the brain of man, analyzes an in- 
teresting article by Dr. F. Marchand, which appeared in the 
Journal of the Scientific Society of Saxony (vol.xxvii, p. 389), 
and an abstract of the same, which may be found in the 
Centralblatt fur die Physiologie ( 1902, p. 294) . Dr. March- 
and has weighed the brain in 1234 cases, usually immed- 
iately after its removal from the body and whilst still en- 
closed in the dura mater. The subjects were Hessians, and 
the results ( which he obtained may be briefly stated as 
follows: 

The mean weight of the brain in the mail sex between 
the ages of fifteen and eighty years was 1400 grammes or 
43# ounces, apothecary weight, and in females it was 1275 
grammes. The brain in 84 per cent of all adult males be- 
tween the ages of 15 and eighty years weighed between 
1250 and 1550 grammes; in about 50 per cent it weighed 
from 1300 to 1450 grammes; in about 30 per cent it was 
over 1450 grammes; and in only 20 per cent under 1300 
grammes. In women 91 per cent of all the adults had a 
brain weight between 1100 and 1450 grammes, 35 per cent 
weighed 1200 to 1350 grammes, 20 per cent over 1350 
grammes, and 25 per cent below 1200 grammes. Dr. 
Marchand found that the brain weight at birth doubled in 
the course of the first nine months of life, and trebled be- 
fore the expiration of the third year. After this date the 
increase was much slower, and slower in females than in 
males. Its definite or ultimate weight was reached in males 
at about the nineteenth or twentieth year, and in females 
from the sixteenth to the eighteenth year. 

The diminution of the mean weight of the brain which 



223 

is due to the supervention of senile atrophy occurs in males 
in the course of the eighth decade, and in females 
of the seventh, though without doubt great individual dif- 
ferences are observable. The increase of the mean weight 
of the brain in childhood follows the growth of the body 
generally till it reaches a length of 70 centimeters inde- 
pendently of age and sex, but from this point onward 
it becomes irregular and is always smaller in females. 
In adults there is no constant relation between body 
weight and brain weight. Still, the mean weight of the 
brain in males of short stature (from ISO to 160 centi- 
meters) is rather less than those of the average height, and 
the same holds good for women under 145 centimeters. 
The smaller size of the brain in women is not dependent 
on the lower stature, for the mean weight of the brain in 
women is without exception smaller than that of males of 
equal height. The conclusions of Dr. Marchand are drawn 
from data which are contained in numerous statistical 
tables. 



In this plate the student has the opportunity of observing the gr^^a- ^3i 
development of the vertebrata of the encephalon. The various ganglia ov» -^F" ' 
senses are analogous in each species, varying but little in size and ge i^e— me 
appearance, the great diversity of configuration depending entirely o *^K^m • 
different degrees of development of the hemispheres and cerebellum. 

The letters in this plate all refer to the same parts in each figure. 

A, Olfactory ganglion. 

B, Hemispherical ganglion. 

C, Anterior optic ganglion. 

D, Testes, or posterior optic ganglion. 
E } Cerebellum. 

F, Auditory ganglion. 

G, Pneumogastric ganglion, or olivary body. 
H, Spinal cord. 

/. Tuber cinereum. 

K, Posterior cerebral ganglion of the cord or thalamus nervi optic # — 

/., Corpus geniculatum. 

m, Anterior cerebral ganglion or corpus striatum. 

//, Longitudinal commissure, or fornix. 

0. Pineal commissure. 

/\ Intercerebral commissure. 

1. Side view of the brain of the Turtle. 

2. Side view of the brain of a bird (the Turkey), with its skull. 

3. The brain of the bird laid open. (From Spur^heim.) 

4. Side view of the head and brain of a Squirrel. 

5. Brain of the Rabbit; hemispheres turned back, exposing the *cere- 

bral ganglia and optic tubercles on the right side; on the le^tf^ s/de 
covered by the fornix or longitudinal commissure. 

6. Brain of the Squirrel; hemispheres separated, exposing the c««~* bf «i 

ganglia of the cord. 

7. Brain of the Rabbit, under surface. 
S. Brain of the Rabbit, upper surface. 

For later illustrations and further study, consult Hui ^<tey, 
Ferrier, Owen, Wesley Mills, Dalton, His and Landois. and 
Sterling, though none, 1 think, have better illustrated the 
subject for our purpose, while this plate serves to kee*!^ the 
«.. me of Sollv in vour mind as one of the immortals. 




THE INTRA-CRANIAL CIRCULATION IN ITS RELATION TO BRAIN DISEASE* 

The heart in return for its innervation from the brain 
and because of its dependence on the brain's close prox- 
imity to it, sends the most and the best of its blood to the 
intra-cranial cavity to nourish first and best of all the cerebro- 
spinal axis, the cerebrum, pons and medulla and ce rebel* 
lum. The heart is the ceaseless servant of the brain and can 
not stop its action even ever so briefly without the brain's 
feeling the suspended cardiac movement impression (mo- 
lecular or en masse) in perversion of its own function* The 
heart ordinarily reciprocally responds in disordered action 
or suspended function to abnormal states of the brain. 
Functional cardiac and structural intra-cranial disease and 
vice versa are often mutually inter- related and functional 
states of heart and brain are often interchangeable a&- 
in the alternating or mutually related cardiac brain dis- 
turbances of hysteria and epilepsy, cardiac vertigo and- 
cerebral cardiac arhythmia. 

1 'Shortly after the blood leaves the heart a very large- 
portion of it is directed into four channels — the two carotiA 
and the two vertebral arteries— that go direct and b)^ 



•The quotation marks In tills chapter refer to Dr. Jaaitt Capple's succinct accouft < 
of ibt Intra -cranial circulation. 

[226] 



237 

branches to the brain, skull and scalp, the brain getting 
mostly all of it. 

"The course of the carotids is upward on either side 
of the wind-pipe. At the angle of the jaw each divides 
into two vessels. One of these supplies the external parts 
of the head, the mouth, pharynx, etc. The other — the in- 
ternal carotid— reaches the base of the skull, and pene- 
trates the latter through a tortuous canal. On entering 
the cranial cavity it divides into three branches. The an- 
terior and middle cerebral arteries supply a large part of 
the front and middle lobes of the brain, a third proceeds 
backward and inoculates with another vessel from a differ- 
ent source. 

"The vertebral arteries take a course less exposed than 
that of the carotids. Each of the cervical vertebrae has a 
projection outward from the side of its body— the transverse 
process. In the upper six vertebrae, each process is per- 
forated by a foramen, and the vertebral artery is transmit- 
ted through this. It ascends, therefore, through a succes- 
sion of foramina till it reaches the upper part of the spinal 
canal. There it pierces the dura mater, and enters the 
cranial cavity, along with the spinal cord, through the 
large occipital foramen. Proceeding forward, along the base 
of the skull, under the medulla oblongata, the two vessels 
gradually approach each other, and at the edge of the pons 
varolii they unite, to form one large vessel — the basilar 
artery. From this branches are thrown off to supply the 
cerebellum and the posterior lobe of the brain. 

"The mass of blood conveyed by these four arteries is 
very large. It has been calculated that they carry one- 
fifth of all the blood of the body. Even if one -half of this 
quantity is sent to the brain, the proportion would still be 
considerable. The brain does not weigh one- fortieth part 



228 

of the whole body, yet it would receive one-tenth of all 
the blood. 

"The provision has been made in the brain to prevent 
such a large mass of blood from impinging too abruptly 
on the delicate brain tissue. In and above its canal through 
the temporal bone, the carotid is curved like the letter S t 
and the vertebral arteries have also a very winding course 
at the upper part of the spinal column, and on reaching 
the cranial cavity. 

"The arterial circulation at the base of the brain is re- 
markable for the manner in which some of the large 
vessels anastomose. From each of the divisions of the 
basilar artery a branch is thrown forward, and it inoscu- 
lates with a division of the internal carotid; and the an- 
terior arteries also communicate with one another by a 
cross branch. A complete circle of somewhat irregular 
shape — the Circle of Willis — is thus formed. We can 
readily understand how important such an arrangement can 
be. It makes provision for a ready and full determination 
of blood being permitted to any part of the brain where a 
demand for it may have been set up."* 

The Circle of Willis and the sigmoid arrangement of 
the internal carotids before entering the brain break the 
force to a great extent of the blood stream if too violently 
impelled from the heart when the heart is under stimula- 
tion. In the brain the arteries all lose themselves in that 
delicate membrane— the pia mater — which immediately in- 
vests the brain. In this membrane they divide and sub- 
divide into extremely fine terminal vessels until before 
they penetrate the substance to nourish the neurones they 
have become almost, if not altogether, brain capillary in size. 
Besides this the cortex and basal arteriole circulation does 

•Capple-lntra-Cranlal Circulation. Edinburgh. 1890. 




' 



not anastomose freely t nor do the different cortex systems 
witn each other. 

The intra-crania] venous system of vessels also con- 

irkably with thai ot other regions. 
-l ln the brain mass it is, like the arterial, practically 
capillary. Only on retching the pia mater do the vessels 
so coalesce as to form veins of appreciable size. They 
then, however, become I conspicuous object on the cerebral 
surface. When the upper part of the skull has been re- 
moved, and the dura mater has been cut away, the most 
s * r iking object which presents itself is the great number of 
dark colored tortuous vessels that present themselves coiled 
' n the meshes of the pia mater. They are seen lying in 
the furrows between the convolutions or crossing the latter 
ir » all directions/' 

The capacity of the veins throughout the body is, as a 
r ule, greater than the arteries they accompany or cor- 
re spond to, especially in the circulation within the skull. 
^^hile the larger arteries are limited in number, the veins 
°* noticeable size are scattered over the whole surface of 
the brain, or lie in fine coils between the convolutions. 

The pia mater or pia arachnoid is a unique complex of 

Ve ssels united by extremely fine fibrous tissue. "Through 

one set of these vessels all the blood that goes to nourish the 

brain must pass, and through another set all the returning 

Ve Hous blood is transmitted. The membrane keeps in close 

c °r*tact with the cortical surface of the brain in all its foldings. 

^hile the dura mater only dips between some of the larger 

Masses, — lying, for example, between the opposing surfaces 

°* the cerebral hemispheres, or separating the cerebrum 

from the cerebellum, — the pia mater not only covers the 

brain as seen when the dura mater is removed, but it dtps 

*° the bottom of every fold, and separates the layers from 



230 

one another. When the convolutions are separated, it is 
seen to lie like a fine velvety pad between the opposing 
surfaces. At certain situations it is continued into the 
cavities or ventricles. In the lateral ventricle in each 
hemisphere, the choroid plexus — a curiously convoluted 
cluster of vessels — is a conspicuous object. If the mem* 
brane be gently raised at any point, numberless extremely 
small vessels are seen to connect its inner surface with 
that of the brain substance. These are so delicate that 
they break with the slightest traction. 

"There is still another peculiarity in the arrangement 
of the intra cranial blood vessels. The veins, instead of 
all converging to form trunks differing only if> bulk from 
one another, are emptied into what are called the sinuses 
of the dura mater. These are channels tunneled in vari- 
ous directions in that membrane. They are fifteen in 
number, five being pairs, and five single. 

"The most important characteristic of a sinus is the 
circumstance that its capacity cannot be greatly, if at all, 
altered. It is formed of tough, inelastic membrane, and is 
so constructed that its walls can neither be made to col- 
lapse by pressure from without, nor to yield to distending 
force within/ ' 

The falx cerebri, which lies between the cerebral hemi- 
spheres, is lodged in a process of the dura mater. Beginning 
in front ,«t the crista gal It of the ethmoid bone in a pointed 
fold Erf the dura, like the point of a scythe, the great longitu- 
dinal sinus runs upward and backward, keeping close to the 
Cranial wall on its superior border, and receiving in its course 
the contents of veins from the pia mater. If a vertical section 
be made, it is found to be triangular in form, the base beings 
outward, Immediately under the cranial wall, the apex point — 
Ing toward the center and base of the brain. It is small 



231 



front and increases gradually in size as it runs backward* The 
mode In which the veins from the pia mater enter it is also 
peculiar. They open obliquely in a direction opposite to the 
current of the blood — that is to say, while the current in the 
sirius is from before backward, the veins, where they open 
,r *t:o the sinus, have a direction from behind forward. 

"The ultimate destination of the blood in the venous 
siriuses is the jugular vein, which is reached by a foramen 
different from that by which the arteries entered. 

*'ln the anatomical arrangement and structure of the 

vessels, the infra-cranial circulation contrasts in several 

re *s|>ects with that of other regions of the body. In the 

^t-i^iritity of blood being larger in proportion to the size of the 

° r e^n to be nourished, — in the free manner in which the 

' ar Rer arteries of a system communicate with one another, — 

Ir> tifie circulation of the brain mass being practically capillary, 

"""i n the circumstance that the larger arteries and veins, in- 

s ^^^id of keeping company, lie apart from one another; — 

a r * ^X in the venous blood being in the latter part of its 

c Ovj* Tse transmitted through channels with tough inelastic 

^^^-lls, we have a series of peculiarities which has im* 

^^^^tant significance in neurological diagnosis and treatment." 

* ^ great preponderance of blood in the brain and the 






*- Ill's nearness to the heart and receiving its first and 

ingest impulse from the heart, particularly in childhood, 
compared with other organs, accounts for the greater 
^portion of circulatory brain diseases in childhood. 

The circulation of the brain being so responsive to the 

*^tes of the neurones as in the many forms of induced 

*~ebral hyperemia of over brain action and gummatous 

^Ventitia as in epilepsy, paresis, insanity, mania a potu, 

" ^^., makes the brain circulation always an interesting 

^Vidy in neurology. In the phraseology of John Hunter, 






232 

the great English physiologist and surgeon of a former 
century, the blood seeks the remotest portions of the brain 
under "the stimulus of necessity." The neurones in- 
ducing the flow and the nerve centers vito-chemically 
appropriating from the blood current the pabulum of their 
trophic reconstruction. 

The main current of the circulation is carried on by 
the action of the heart. It goes through the arterioles 
partly because of the vis a tergo it receives from the 
heart, partly through the propulsive contractions of the 
arterioles and through the induction dependent on the needs 
and parts or organs. In fact the local distribution of blood 
is to a great extent regulated by local demands and con- 
ditions. On this subject Cappie says: "As a matter of 
fact we find that the supply of blood to individual parts is 
usually regulated by the need for it. When the mammary 
secretion is being established, the afflux of blood to the 
gland becomes several times greater than when its function 
was dormant. When the mucous membrane of the stomach 
is stimulated by food and the secretion of gastric juice be- 
gins, the surface becomes intensely injected with rapidly 
moving blood; then, after digestion has been completed and 
the stomach is empty, the membrane again becomes com- 
paratively bloodless. In short, wherever growth, and espe- 
cially where the transformations that accompany functiona 
activity go on with greater vigor than usual, there is an 
increased determination of blood towards and through that 
part." We have a good illustration of this in induced cere- 
bral hyperemia following passionate mind excitement, a blow 
on the head or the rush of blood to a part after friction or a 
moxa or blister sinapism through arteriole dilatation brought 
about through the paralyzing influence of the hold of the 
vaso- motor nerve mechanism over the arterioles, and this is 



f 



233 

brought about through a vito-chemical efferent influence 
&oing to the vaso-motor centers, which maintains the nor- 
mal relations between the tissue and viscera and the blood 
supply in health and cause those abnormal relations in 
disease which we call hyperemia, anaemia, etc. It is thus, 
"With this local help, that the contraction of the left ven- 
tricle is powerful enough to send the blood current around 
^he body to the right auricle. The circulation is completed 
**y the contractile vital and chemical assistance at the in- 
termediate arteriole and capillary stations. 

"As the vital affinities," quotes Cappie from Alison, 
« « 

obviously act with greater energy in individual parts of 

^he body at some times than at other, (e. #., at the lungs 

^'Jring inspiration, at the stomach during digestion, or at 

*He uterus during gestation), we can understand how local 

^^termination of blood should be produced (by attraction 

r ^ther than propulsion) by causes exciting the vital actions 

** the ends of the arteries. The increase of nutrition, se- 

c - r ^tion, or excretion, is in such cases, at least in the first 

1 ^stance, the cause, not the effect, of the increased flow 

**f blood to the parts concerned; just as the excitement of 

^ital action in the branch of a tree exclusively exposed to 

'Wle sun, is the cause, not the effect, of an exclusively in- 

^reased flow of sap into it."* 

"Molecular tissue changes cause the movement of fluids 

in capillary tubes without the aid of evident mechanical 

impulse. The movement in the bud initiates that in the 

stem; the molecular activity in the foliage conditions the 

ascent of sap from a long distance below." 

A similar process for purposes of neurone nutrition 
goes on between the nerve cell and its appendages which 
make up the nerve centers and the final microscopic 
terminals of the arteries. 

•"Outlines of Physiology," 3rd ed.. pp. 6J-63, 64-70. 



234 



FIG. 115. 




'd'aprfcs M. Charcot). — Schema de la circulation arUrielk «f* it fear 

derenrcphale; — C, C. carolidcs internes; — C.A, eer*br»U>§ an tf r lew : — f^ 
S. art.Vcs sylviennes; — V, V, arttres vertebrates; — B, trone bajUalr*; — 
CParteres cerebrates posterieuroa; — 1, 2, 3, 3, 4, 4, arteres nourrtoUffos. 

nr?^' 3 ' 4 ** 4C '' ^° W *- V *-*^ W *»'« V J3 (XrC«Yv4ft. 




236 



FIG. 118. 




Fro SOS;- Portion of the web of a fro*'* foot as seen under a low magnifying power, showing 
ttif bk»M-ve*»eK and In one corner the pifnnent-spots (after Huxley >. o. amaU artenrs 
inrt»-n..l. >,-, i . Mimll v^ms The smaller vessels are the capillaries. The course of the 

Wood is indicate*] by arrows. 



237 



HOW THE VENOUS BLOOD IS COLLECTED FOR RETURN FROM THE 

BRAIN TO THE HEART, 

FIG, 119. Fh,. 120. 




JjfiZZ 



•at fat* of Hack 



Interrelation of the transverse 
and cavernous sinus with the ex- 
ternal veins (*). (After Lea be ) 




Basal aspect of the sinuses, 
showing ^interior ophthalmic and 
Torcular communications. 



the masotl, building a wall of brick or stone or 
shaping its corners or arches, calls the hodcarrier with his 
bricks and nv>rtar and the hodcarrier responds to his call, 
so the neurone or an aggregation of neurones into a nerve- 
center or these aggregated into an organ when in a state 
of normal health, rill upon the blood -carrying vessels of 
the human organism for the materials they need tor their 
building and rebuilding or repair. In health they take no 
more and no less than the needs of their physiological 
life, but in morbid states they take less or more and develop 




238 

local hyperaemic or anaemic conditions according as they de- 
mand of or receive from the blood current too much or too 
little nutrition or suffer from too great or deficient blood 
pressure. Or the neurones and nerve-centers may act 
abnormally, if the blood stream or the spinal fluid becomes 
toxhaemic and carries blood poisons to the neurone beyond 
its power to withstand and yet perform its normal func- 
tion. Morbid results then follow in the neurones, as in the 
psychic neurones and psycho-motor neurones toxically im- 
pressed by excessive alcoholic indulgence. 

Though the blood is the life stream of organic life, 
inherent conditions in the neurone determine and condition 
the blood's distribution and appropriation to parts in 
healthy states. A germinal spot builds itself into definite 
being from its environing media, made from the blood. 
From this environment it appropriates the pabulum of 
growth and converts it into organic life and evolution. Thus 
it evolves into the germinal segment of the brain and 
spinal cord and completes a neuraxis with its vaso- motor, 
psycho-motor, pure psychic, ganglionic, trophic, and motor 
centers, which furnish the governing centers of the heart's 
impulses and the arterioles' contractions and dilations and 
make a marvellously life-endowed being of a community of 
centers of neural chain related neurones of organic life. 

The overflow, or lack of blood, sent to a part may pro- 
ceed from morbid states of a distant vaso-motor center as 
in epileptic convulsion, an overcoming and weakening 
physiological resistance in the neurones of other nerve- 
centers or altering the functional display of organs, espec- 
ially of the brain. 



FIG. 121. 



239 



^yoTv*. . ^«*. ov»%. Ir.v £ . 



*** 




/ 



Nora*!* Fro-CapHtera mi dw> 

(tofeirn. BnM B*ob*ofetmc. 

Weimrt'i EUstfc»-7Bitug . 

« rotbe BlutkOrpercbM fm Lumw. 

ft Esdothdkera. e Butte. 4 tinfteb* 

Mftdefawebtligc dcr AdveaUtte. • extim 

tdvntltiilter R*uo. /UUakwMl*. 

HlrBpMWKaym. 








OtoovC \>vCu£\.*v<^ (tX\Xexc Moti«v« ©.wo Cuccj 



242 



FIG. 126, 






If 



m 






[d'apret M. tlurclV — Coiiw ti -inivtrMtr dc* h*mi*ph*rts eertbraux 
fatteii un rrnliwtrrrn mritre'du chiaxma dm nerf$ Ofithjuei. — Aftiret du 
torm *trie; — (jb t ctiitiicin dea ntffi opti^-iies; ; — B. section do It bandelette 
opdquo; — L, nuyiu IcrUi --p» strle; — t, capsule interne, ua pled 

etc la cotironnc ravonnante dtf Rril ; — w, noyau cauiKi du inlra-tcbtrkctlaire da 
firps »lrie; — E,Vap*uk ciltnic ; — T, noyau Uvaironue ou airantmur, 
dfttOBVolullOfl «lo llaNlli; — VV, coupe des vcnlriculea lateral, — P,P< pilior* 
du tHfOdf; — O, siibttanwj grUo du Iruisitmo I'eutricule qui M continue vm 
arriero rtv« la louche t>plUiu<\ 

Territtjirts MMcutaire*; — I, artAfe cerebrate antrrioure , — U, arlar* af»- 
Tirana ; — III, arlero cerebrate posiericttre : — I, artdre caroliie interne; -*£* 
artere tyMenne; —3 art>re cerebrate anl^neure ; — 1,4, arlerei eticrnet 7a 
corps slrie ou knUculg,' strives ; — 5,5 f arlercs internes du corp* tlrie (arteret 

li-JjUcul:iirc* . 

C 1l. GKuutiw , 3, 5*c\\aiv O^C'vc ivatTV*, l^cTt^CvcAar tvux.\ews 



O. C^ra.vt s^Vic^cw^ce. ch^VvVtcV va>«&.Yvc>Jt* vot^c\AXtvjv^A 



itvlox^ OLx\.«,t 



t& 



\?©«?Cave\oc 



tareVtcA Oc^t^Uj.yt lv&«<**o\ ccv*©Cvo oA«a^, ^- 5^LvUx^. ©-Vta,*^ 
J. CLwX*«\er C»«bieoCl CX^a/c^,** 6 S^?t« ? wa\ 0-A*>c*v«.V •£ <V*jfc 



The lenticular striate artery Is the principal artery of cerebral b 



rhage. 



- 



I 



243 



FIG. 127. 













' )wm 



puler. cells. 



5pv£*r*ttt with its 
. vis Jc ui&r jiroc «*». 



Sptd** e£im«n£» 



.DeJendratio.il of Ncrvr-celU in CoTtex 
with proliferation c( tho Spidur or Scav^n^er-ctHi;.. 
Section from fifth Cortical layer in Motor to^ioil 

. The above shows an arteriole of the brain degenerated by chronic 

.. °**olism and the neighboring degenerative changes of the neurones sup- 
*"*<* by it. 



CHAPTER XXII. 

ELECTRICITY AND ELECTRICAL APPLIANC€S. 



Electricity in medical practice is the minimization of the 
lightning — with batteries in skilled medical hands the time 
for fools in the practice of medicine has passed. Likewise for 
fadists and fakirs and the reckless, fraudulent quacks who make 
pretense of science and, for filthy lucre, misapply this power 
so potent for the weal or woe of man. The battery and the 
static machine are not things to play with, especially about 
the brain and other nerve centers. They may destroy as 
well as conserve structure and function. In paralysis there 
must be channels of nerve conduction, anatomically reestab- 
lished before the contractile power of Faradism should be 
brought vigorously to bear on organic movement, otherwise 
you may destroy paralyzed function that is returning to 
motor neurones by prematurely over violent electric con- 
tractile stimulation. Electricity is a splendid aid to the 
neurologist; one of the best aids he has when properly, 
and kindly used on the patient. 

There are some things we do not quite understand 
about electricity and until we do we must cultivate its 
acquaintance with caution as a therapeutic agent, being sure 
we are right as we proceed with its employment in treat- 
ment. It is friendly to our purposes in several ways, but 
it is also a terrible enemy and we do not yet quite under- 
stand thoroughly its precise nature. We know it to be a 

[244] 



Potent force in nature, terribly destructive, as we see in 
the work of the unchained thunderbolt, when the lightning 
strikes man or the works of man. We call it a subtle 
fluid. It is latent in nature for our use until we arouse it 
into activity by friction or chemical action. It is the docile, 
faithful -serving dog if controlled aright or the destructive lion 
if unrestrained. A power that may move mountains, may, 
■* judiciously minimized, curatively impress a neurone, cere- 
bral, spinal or peripheral. 

The great big static machine, looking and impressing 
^he imagination like an immense dynamo, I do not commend 
to your use, but instead a moderate sized static machine 
'^ith just potentiality enough to favorably affect your 
Patients without frightening them and a current applied 
^^ithout violence. The x-ray machine may be larger but 
s Hould be separate, and in another room. The cautery 
^^ttery or the power of the cautery battery of course, should 
"^ greater than for ordinary use and the faradic current 
s »*OuId be as gently used as will accomplish the necessary 
^^dical purpose. For the successful use of electricity in 
•^^ctice not quantity so much as quality and skill are 
^^^ded. This applies to the static breeze as well. An 
^^tcellent rule in the use of electricity is, to paraphrase the 
***TgicaI precept in regard to the use of water douches and 
****essings, to conform to the feelings of the patient. Do 
**Ot persist in running the static roller up the hypersthe- 
nic back of spinal irritation, emitting or drawing sparks that 
l>ain or shock and excite dread and terror. Use it gently on 
the naked skin with those whom the current pains much. 
There should be more of the placebo in your methods with 
these morbidly sensitive spines. Use the roller gently and 
press it closely on the naked back; it otherwise used it 
may greatly harm the patient. 



246 

The gentle diffusion of electricity through the system 
of the patient, not in over doses, on an insulated static 
stand and not exhaustingly continued, supplements other 
treatment. It improves molecular activities, like a walk in 
an ozonized and moderately sunshiny atmosphere or like 
the static breeze. Some ozone is also generated by the 
friction battery and diffused in the air in the room about 
it. The constant current from forehead (positive pole) to 
nape of neck, (negative pole), six or more milliamperes 
with inch and a half sponge electrodes may be used to 
contract the cerebral arterioles in hyperaemic headache and 
stronger in facial neuralgia, sciatica, etc. 

The static and other currents may be used likewise for 
pain, but not about the brain or eye until you become so expert 
an electrician that you know the subject and your tools better, 
than 1 can teach you in this hour. If you decide to use 
electricity in your practice you must make a close study of 
it and qualify yourself to use it aright. Therapeutic electro- 
cataphoresis will interest you and serve you, if you strive 
to understand it well. Cataphoresis carries medicines elec- 
trically through the system and it helps to increase their 
potency, in places, as 1 think the static insulation does in a 
general way. 1 have referred to the use of electricity in 
cephalic galvanizations in a previous lecture. It is useful 
for headaches and many affections of the brain of a 
hyperaemic character, that is, constant current galvaniza- 
tions only, and the x-ray is now on very promising trial for 
cancer. 1 would try it for brain tumor but you will not be 
expert enough in the beginning of your practice to risk 
this procedure. It has been successful. 1 would advise its 
use with extreme caution tor osteo- sarcoma and malignant 
growths under or on the cranium. It has removed epithe- 
lioma. 



247 

You may use the gentle constant current with safety, 
however. Incidentally to my neurological practice some results 
with external tumors of which I have spoken elsewhere, 
many years ago, were very satisfactorily curative, which led 
me to the use of the constant current galvanism in cases 
of suspected brain tumor and gummata in epilepsy and its 
use has been a routine practice with me in epilepsy of all 
kinds for a third of a century with very satisfactory results. 

Epilepsy is by no means the inevitably incurable dis- 
ease it has been unwisely proclaimed, by men of authority 
of the past in medicine. 1 have had many epileptics re- 
cover under persistent cephalic galvanization, coupled with 
long continued treatment over several years. 

Electricity may be used as a tranquilizing agent or as 
an excitant. The former is the best to use generally, in 
neurological practice. It should be so employed as to soothe 
and to calm, not only nervous conditions, but nervous 
apprehensions and we should be careful that its psychic 
impression, by suggestion, is not counteracted by over vio- 
lent and too prolonged and exhausting applications. 
Sometimes, however, we desire to produce a markedly ex- 
citant impression, as in chronic forms of paralysis, when 
precautions for ordinary nervous excitement need not be 
so cautiously considered and sometimes we may wish to 
destroy tissue, as with the cautery or x-ray, but even then 
we should consider the patient and remember that he has a 
delicate sensory nervous system to deal with and it is 
closely connected with perceptive sentient centers in the 
cerebrum. While destroying disease, we should be careful 
not to destroy vital cell life. Take care of the neurones. 

Many styles of batteries and machines for generating 
electricity are in use which it is not my province to descant 
upon. I show you some samples which will answer your 



248 

purpose and practice.* Many electrodes also for applying 
the fluid are employed and others are being constantly devised. 
You need one with a current interrupter in the handle, if there 
is none on the battery, for testing for the reaction of degen- 
eration until you become adepts at opening and closing the 
circuit otherwise. 1 show you some patterns devised by Erb, 
who recommends uniformity in size of medical electrodes for 
conformity to a common standard in medical case recording, 
where electricity is used. I select Erb's also because he 
is something of a pioneer expert medical electrician after 
Dr. Benjamin Franklin and John Wesley. The latter two 
would be classed as quacks in the business now a days. 
They were novices. There was more Methodism in Wesley's 
theology than in his therapeutics and more science than 
caution in some of Franklin's experiments, but he made 
mankind greatly his debtor thereby. He risked his life 
in the celebrated kite and cloud experiments. Your 
electrode should be supplied with a good wet sponge 
or cover pad of cotton or porous woolen cloth, but neither 
one need be so large as the one of Erb's, nor precisely of 
the shape. 

If you use electricity, and you ought to, you should 
join with a few medical men and syndicate your business, 
making a syndicate of three or four and regulating the 
demand on your time so that one of you could study and 
practice the subject and accumulate the necessary know- 
ledge and appliances for its successful employment, to the 
credit of the profession and for the highest success in 
practice. It is a power for good or ill in medicine accord- 
ing as it is wisely or rashly employed. 

1 do not commend the use of electricity to the ex- 
clusion of associated suitable medication, in practice. The 

* Sec previous chapters. 




249 



exclusive medical electrician is usually lacking in necessary 
medical knowledge and consequently inclined to underrate 
or ftjnore medication and to overrate electricity, and to be 
lacking in diagnostic ability. 

The best medical cataphoresis in practice is the in- 
ternal administration of a well adapted medication, based 
on correct diagnosis and large neurological experience, com- 
bined with suitable electrizations, 



CRANIO-CERVICO. FACIO-CLAVICULAR POINTS, 
THE iNTER-SCAUiM. MirRA-CLAVICULAR POINT OF ERB, 



FIG. 128. 



i of central 
toatoltitloos. 

Jtefto* of ihird 
frontal toflTOlo- 

tkxk and bland 
of ft ell. 

M trmporalti- 

(U. branch. 
M.branch. 
Trunk. 
L. branch. 

N, auocuUr post. 
M. splenitis capita 

M flemocleido- 
roa&toUI. 

*.ncc**aor Wll. 



K.ck 

II . tborack. lanf. 
(H,Mrraiuaanu 

mm* 

W. phrenioa. 




M waciea of hjoA 



S iharw 
■ 
ral nu>ut.) 



*^^^Z&te£^^^^'' M ' 



X This is the place of origin of the birth-arm palsy ot Duchenne, after 
cross-arm presentation and turning and of other brachial plexus paralyses* 



250 



FIG. 129. 



tltrve a?*»*. 

i « fa i I 




i as? ;. fc '-i ! 1 

-»ggg 



251 











FIG. 130. 
















Ncrtu* « rum 


liv. 








Ne 


\ n» tibialis. 




1 

2 

w 
V. 


5 

e 

x~ 


i Mi 

x x x 


*3 

i 

X 


i" s" 


«" 


e 

S 




1 


as a 



10 

Of 







v 
H 



fie 
UJ 

1 

o 
-J 



:* 



ill 1 



Hi 



<1 



X j^i 



.«* — ' ** 



x X XX"" 


' Nerv. peron. 

M. tibialis ant. 

M. ext. digit. 

coram, long. 


a 
o 

i 

X 


i 
& 

X 


3 

If 

X~ 


ti* 

Sis 


StVrru* oluuiaiorius. 


Menrus tibialis. 


Ncr*u 


k !>cruneus. 




e t « 

(ill. 

fc* XXX" 


i 

H i 

2 X X 






x u x~ 


1 




•so. .£ a 



CHAPTER XXIII. 



THE DURA; ITS SINUSES AND DISEASES: A CURSORY ANATOMICAL 
DEMONSTRATION.* 

By the assistance of Mr. Norris we have sawed through 
a line around the skull, beginning about half an inch above 
the supra orbital ridge in front, going through the two 
tables of the skull anteriori, which inclose its frontal 
sinus, (not one of the sinuses we are to consider today), 
through the three walls of the squammous and the thicker 
and harder petrous-temporal region and the yet thicker but 
not denser occipital protuberence behind. Prizing up with 
a chisel the skull cap we have just cut out, for 
we have not gone with our saw entirely through 
the inner table of the skull, we expose this tough, 
glistening, fibrous membrane, the dura mater or hard 
mother membrane of the brain, showing also the 
nutrient meningeal arteries between it and the skull cap, 
which we have taken away. 

This dense white fibrous membrane which our ancient 
fathers in anatomy thought when they christened it, gave 
rise to all the other fibrous membranes of the body, you 
notice was adherent to the inner surface of the skull just 
removed, especially along the median line where the sagit- 
tal suture runs back to the lambdoidal. As I continue to 

• Holden's Anatomy has been mostly followed In this description, and wherever quo- 
tation marks appear In this chapter they refer to this excellent work. 

[252] 



253 



remove it you notice it is adherent to the other bones, es- 
pecially the petrous, temporal, the cribriform of the ethmoid, 
the sphenoid, the foramen magnum or great foramen, and 
that it is studded with Pacchionian bodies along this median 
line, which was here attached to the skull. On its smooth, 
shining inner surface it is lined by endothelial cells* 

The dura forms the endostium or internal periosteum of 
the skull* Underneath it, is the subdural space. In front it 
projects downward through the foramen coecum and cribri- 
form plate of the ethmoid bone, bringing the lining walls of 
the nose in intimate and remote connection with the venous 
circulation of the head in certain states of venous congest- 
ion of the brain. It connects with the optic foramen, 
sphenoidal fissure and orbit* Its nervous supply is from the 
fourth and fifth, including the Gasserian ganglion filaments 
and sympathetic fibers. Besides forming the cranial en- 
dostium it supports, encloses and protects the lobes and 
otherwise serves the brain. It forms the falx cerebri, this 
sickle shaped partition between the hemispheres, carrying 
the great longitudinal and lesser longitudinal sinuses, the 
falx cerebelli and the tentorium cerebelli. This fibrous tent, 
as the name tentorium implies, stretches across and under- 
neath the anterior brain and over the cerebellum. "It forms 
the sinuses or venous canals for the return of all the blood 
from the brain on its way back to the heart and it sheathes 
the cranial nerves as they make their exits from the skull. 
It forms the supporting and dividing partitions between the 
cerebrum and cerebellum and the tentorium, holds forward, 
in its place, the cerebrum and backward in its place the 
cerebellum, " 

The tentorium is sometimes found ossified, in lower ani- 
mals and by this arrangement confining the respective greatn 
and lesser brains more securely in their respective places, may 





254 

account in cats for the more secure and superior safety over 
that of man, of the feline tribe in jumping head downward 
from a housetop before a boot jack or "any old thing" 
hurled at Tommy and his musical friends. But human 
acrobats and gymnasts do similar feats. "The tentorium is 
attached to the transverse ridge of the occipital, the supe- 
rior border of the temporal bones and to the posterior and 
anterior clinoid processes of the spenoid bone. In front, as 
as you see, the tentorium arches gracefully over the crura 
cerebri, while the point of the falx cerebri begins at the 
crista galli or coxcomb like process of the ethmoid and 
widens as we trace it backward to the manubrium or 
handle of this sickle shaped membrane, where it joins the 
tentorium cerebelli. The falx cerebelli is also widest 
and longest across at its junction with the tentorium. 

1 do not know for what use these Pacchionian bodies 
or glands were formed. They are probably products of 
membranous degeneration. They usually begin to appear 
about the third year, always by the seventh, and increase 
as life advances, and are said to receive the fluid of the 
subarachnoid spaces when they have been experimentally 
injected. We know too little about them, considering that 
they were discovered by the Italian, whose name they bear, 
as far back as 1705. Perhaps they may have some im- 
portant nerve nourishing, fluid overflow function or some 
electro-chemical relation to the brain awaiting your elucida- 
tion. Here is another opportunity for your distinction. 

SINUSES OF THE DURA MATER.* 

The blood of the cerebral circulation is returned 
through canals or sinuses formed by the dura mater, (a.s 



♦This anatomical description is based on and mainly abbreviated from Hold en* 
Anatomy, the author's favorite dissecting room manual for this subject. 



255 

we have already seen in a previous lecture) produced by 
the dividing of the dura into two layers, as shown in Fig. 
131, representing a vertical section through the falx 



FIG. 131. 



Jk&voX Cross Sk&o«v of FoAxCewaWi 
Line of Day* 



Sk 




x/yO.LoAjj 



z.— 



I*& bono. 
4 




S/NUh 



srw/sta. 



Dhowi*a end view or SvpeRioR AND inferior LomamoiHtL 
'.*Kt3.Ua*or FAOL, DiPM/¥Q SOW* &*T*wur csr^gml HBMltPHBRES. 



cerebri, showing schematically a cross section of the supe- 
rior and inferior longitudinal sinus. They are lined by the 
same smooth membrane continuous with that of the venous 
system. Their unyielding walls resist the pressure of the 
brain about them and the blood pressure within them. 
The dura mater has fifteen of these sinuses. Let me 
recall them again: Five pairs and five singles. The 
five pairs are: the lateral, superior petrosal, inferior petrosal, 
cavernous and the occipital. The five single are: the su- 
perior longitudinal, inferior longitudinal, circular, transverse 




begins very small at the foramen coecum, it gradually 
increases in size in its course backward, and opposite the 
internal protuberance of the occipital bone, opening into a 
large vein somewhat triangular, the torcular herophili or the 
confluence of the sinuses. "It then divides into the right and 
left lateral sinuses, they being generally the larger. Besides 
numerous veins from the cancellous texture of the skull 
cap, the superior longitudinal sinus receives large veins 
from the upper part of each hemisphere of the cerebrum, 
and an emissary vein through the parietal foramen. Do 
not forget ,l that these veins run (as a rule) from behind 
forward, contrary to the course of blood in the sinus, and 



257 

that they pass through the wall of the sinus very obliquely, 
like the ureter, into the bladder. The probable object of 
this oblique entrance is to prevent regurgitation of blood 
from the sinus into the veins of the brain. The superior 
longitudinal sinus is triangular, with its base upward, and 
its cavity is intersected in many places by slender, fibrous 
cords, termed chordae Willisii.t Their precise use is not 
understood." 

You noticed that after stripping it from the cavity of 
the cranium and taking the brain out of the cavity, we cut 
through the dura mater with a pair of scissors, on a level 
with the sawn calvarium. We now strip the dura mater 
from the brain leaving its smooth, convex surface exposed. 
"Two white, flat nerves, the optic, come into view prior to 
their leaving the skull through the optic foramina; these 
must be divided and the ophthalmic arteries which lie un- 
derneath the corresponding nerve, cutting each pair of the 
twin nerves first on one side and then on the other, 
from before backward. In the middle line fixed firmly in 
the sella turcica, lies the pituitary body, attached to the 
brain by the infundibulum." This is the important body 
which Sajous has lately brought into prominence. "The 
round, white nerves, the third, are on each side, 
lying on the inner free border of the tentorium cere- 
belli, immediately behind the anterior clinoid process 
of the sphenoid. Dividing these, we cut through the 
tentorium cerebelli close to its attachment to the pos- 
terior clinoid process and the upper border of the 
petrous portion of the temporal bone, as far back as the 
lateral sinus. Immediately external to the third nerves are 
the slender fourth nerves; and still further outside are the 
fifth nerves. We cut these through, when the seventh pair 



tSo called* after Willis, who first described In his work. De Gerebrl Anatome. 1664. 



258 

come into view as they pass backward and outward toward 
the internal auditory foramina. Cutting these we notice the 
two sixth nerves running directly forward to pierce the dura 
mater covering the basilar process of the occiput. Dividing 
these three, other cranial nerves come into view, behind 
and internal to the seventh; anteriorly is the glosso- 
pharyngeal immediately, is the pneumogastric and poster- 
iorly is the spinal accessory, whose origin is in and below 
the medulla and foramen magnum* Thrsr all emerge 
through the jugular foramina* Below and internal to these 
are the hypoglossal nerves, which usually pass through the 
dura mater into fasciculi/ 1 The spinal cord has, you see, 
been cut through far down so as to show the relation of 
the two vertebral arteries, and the spinal portions of the 
spinal accessory nerves, before this brain was taken from 
its bony incasement. 

The inferior longitudinal sinus, smaller in size, runs in 
the inferior free border of the falx cerebri and terminates in 
the straight sinus at the anterior margin of the tentorium. 

The straight sinus is the continuation of the inferior 
longitudinal running along the line of junction of the falx 
cerebri with the tentorium cerebelli, and terminating in the 
torcular herophili at the divergence of the two lateral 
sinuses. It receives the inferior cerebral and the superior 
cerebellar veins and also the two venae galeni (Figs. 132 
and 133) which return the blood from the lateral and the 
third ventricles of the brain. 

The cavernous sinus is so called because intersected by 
numerous cords extending along the side of the body of the 
sphenoid bone, outside the internal carotid artery, receiving 
the ophthalmic vein from the orbit through the sphenoidal 
fissure and the anterior inferior cerebral veins. It commun- 
icates with the circular sinus which surrounds the pituitary 




Communication vtfffc wfe* 
ud cftTemoui ilnui nitb th* titcnuJ Tiiiw. (•> (After Leu be ) 



260 

body. It divides into the superior and inferior petrosal 
sinuses. 

The circular sinus or rather vein surrounds the pituitary 
body (see diagram, Fig. 134) and communicates on either 
side with the cavernous sinus. 

The petrosal sinuses lead from the cavernous to the 
lateral sinuses, two on each side. The superior runs along 
the upper portion of the pars petrosa, in the attached bor- 
der of the tentorium cerebelli; the inferior (larger) runs 
along the suture, between the pars petrosa and the occipi- 
tal bone, ending in the lateral sinus just before this termi- 
nates in the internal jugular vein. The superior petrosal 
sinus receives the inferior cerebral, the superior cerebel- 
lar veins and a branch from the tympanum; the inferior 
sinus is joined by the inferior cerebellar and auditory veins. 

The transverse or lateral sinus extends from one 
inferior patrosal to the other, across the basilar process of 
the occipital bone. It communicates below with the an- 
terior spinal veins. 

The occipital sinuses surround the margin of the 
foramen magnum, run into the falx cerebelli and uniting, 
form a single sinus, opening into the torcular herophili. 
They join inferiorly with the posterior spinal veins. 

The several sinuses join opposite the spine of the oc- 
cipital bone to form the torcular herophili or press of 
herophilus, after the celebrated anatomist, who first discov- 
ered it. "It is a triangular reservoir, with the base below, 
and presents six openings, namely: that of the superior 
longitudinal sinus, those of the two lateral and of the two 
occipital, and that of the straight sinus. The term torcular 
is an incorrect version of the original word o-wXiJv (a canal 
or gutter) employed by Herophilus." [Holden.] 



261 
LATERAL SINUSES. 

"There are the two great sinuses through which all the 
*>Iood from the brain is returned to the jugular veins. The 
r *ght being usually larger than the left commences at the 
* nternal occipital protuberance and proceeds at first horizon- 
tally outward, enclosed between the layers of the tentor- 
ium, along a groove in the occipital bone and the posterior 
1 *~rf^rior angle of the parietal. They then descend along 
^•^^ mastoid portion of the temporal bone, indenting the oc- 
cr Sl^ital bone, turn forward to the foramen lacerum posterius, 
^^rminating in the bulb of the internal jugular veins, 
*V-*ere they are joined by the inferior petrosal sinus, having 
*^o in some subjects other outlets through the foramen 
astoideum, or the posterior condyloid foramen of either 
^i^3e. They receive blood from the inferior cerebral and 
^-^^rebellar veins, from the diploe and the superior petrosal 
^^ *ius, and communicate with the veins of the scalp through 
^^^irrissary veins, which pass through the mastoid and pos- 
^^^rior condyloid foramina. 

The diseases to which the dura mater membrane and 

^^.s sinuses are liable are chiefly traumatic, general and 

^ , Specific inflammations, thrombosis and compression and 

^^lrombi resulting therefrom. Inflammations seldom involve 

"^lie dura alone but usually conjointly implicate the subjacent 

^membranes, the arachnoid and pia or, more properly called, 

^ think* the pia arachnoid, as these two membranes appear 

"Vo be an infold about the brain like the pleura about the 

^ung. Remember the memorial word which 1 have given 

^ou in our dead-room demonstrations, d. a. />., (meaning 

*om without inward) dura, arachnoid and pia. Meningitis 

may be entire, or circumscribed to different meningeal 

areas as basilar and vertical. It may be cerebro- 



spinal, as in the epidemic form of that disease, called 
by the older writers spotted fever or cerebrospinal 
fever. It may be due to syphilis and give the gam- 
matous form, or to phthisis and appear as tubercular 
meningitis, or it may be caused by the pneumo-coccus or 
gonococci, and appear as pneumonic or gonorrheal forms, 
or it may be prevalent or come from various other kinds 
of blood-poisoning. 

Phlebitis may involve the brain sinuses from causes 
that produce inflammation elsewhere and such inflamma- 
tions may cause coagulations and adhesions of the venous 
blood to the walls of the sinuses or pial veins, causing the 
condition known as thrombosis, to which we have referred, 
from which small sections of fibrin may be detached and 
carried into the current of the circulation as thrombi, and 
these may lodge elsewhere and act the same as emboli, 
closing up blood vessels and causing distant embolism. 

Much mischief may be done to the delicate brain by 
the pressure and destructive change wrought in the brain 
even by a single thrombus located in a vital spot. 

Systemic meningitis usually involves the pia-arachnoid> 
while the traumatic meningeal inflammation generally in- 
volves the dura. 

More harm is done to the brain by involvement of its 
meninges than by implicating its deep substance. De- 
pressed fractures of the brain and direct and counter stroke- 
or conire coup concussions, often seriously involve the dura^ 
and its subjacent membranes and their blood vessels and 
give rise to congestive blood pressure states and epilepsy 
and epileptiform disease. If you remember the distinctiorm 
we made in a previous lecture between neural and ad — 
neural nervous disease you will recognize that meningeal k 




263 

and sinus diseases, deranging the brain's functions often 
begin as extra-neural brain disease. 

When the dura mater is involved exclusive of the other 
meninges in inflammation, this condition is called pachy- 
meningitis. When the pia arachnoid is involved to the 
exclusion of the dura in inflammation, the condition is 
called leptomeningitis. 

The under or inner surface of the dura is usually the 
seat of inflammation except when caused by external 
trauma and then cranial ostitis may be associated with 
the endostitis or epidural inflammation. Extravasations of 
blood often occur in connection with dura-matritis and then 
the condition is called pachymeningitis hemorrhagica interna, 
and when these hemorrhages become encapsulated they 
are called hematomata durce matris. 

These hematomata of the dura mater often harmfully 
press on the brain, compromising its functions and causing 
coma, convulsions, paralysis, delirium or insanity. 

The meningeal arteries supply the central dura mater 
and its innervation is derived chiefly from the trigeminal 
nerves. The pia arachnoid is similaily innervated and 
from the facial and spinal accessory, glossopharyngeal, 
pneumogastric, the third and the sympathetic. This last 
nerve accompanies the many vessels of the pia. 

The dura mater is what its name implies, the hard 
membrane, in contrast with the other two brain coverings 
which are soft and easily torn, one of which, the pia 
mater, being very vascular as we have seen, and the other 
being without vessels and both being delicate. 

Although the brain is pretty much a plenum, the peri- 
vascular spaces and ventricles have communication with 
the spina] canal and thus the cerebro-spinal fluid admits of 
some arterial hyperemia and increased vascular distension, 



264 

and pressure in localities of the brain especially, if not gen- 
erally, throughout the brain and the turgid arteries and in* 
creased rapidity of their circulation may cause cerebral 
congestion, giving pressure states of the brain in the arterial 
and venous areas and causing hebetude, coma and para; 
Sometimes the venous blood pressure is fortuitously relieved 
by epistaxis through the foramen caecum, passing out through 
the nares. You may also have anaemia as well as hyper- 
emia cerebri for the same reasons. 

In ana?mia the cerebro-spinal fluid of the perivascular 
spaces around the arterioles and the ventricles incre.: 
after maintaining a semblance of normal blood pressure on 
the neurones, without normal nutrition, and the brain may 
functionate in consequence in a feebJe but normal manner 
in anaemia. Besides, there may be hydremia. 

It is not good therapeutics to arrest an epistaxis while 
the pulse is full and strong and rapid (above seventy-four 
to seventy-eight). Sometimes, in some highly congested 
states of the brain, it would be wise to bring on bleeding 
from the nose or arm. A weak pulse, bleached features and 
faintness demand the immediate arrest of epistaxis. It usu- 
ally stops spontaneously when fainting takes place. If the 
bleeding is known to be connected with previous or present 
ana?mia, and blood depraved states, as in the adynamia of 
typhus or typhoid fever and other pernicious blood states," 
even though there be delirium and other head symptoms, 
bleeding from the nose is not to be encouraged. 

If you have a plethoric, full-blooded patient with con- 
gestion of the brain, in whom nose bleeding begins every 
day and finally stops of itself each day, let this bleeding 
go on daily unless your patient faints from it. Give him 
a daily chologogue cathartic and bromides, half minimum 
doses of digitalis, some pepsine, other digestives and a mod- 
erately low diet and keep him free from all brain ex- 
citement. Give him no alcohol stimulants. 




Nona*!* Yao* tut dr r Pin n»l*r A** 

Wdjprl'i K lut icm F*i bung 

a Intimft 7EtniwhOli<rti*) b KWu* 



CHAPTER XXIV. 



CEREBRAL EMBOLISM, THROMBOSIS AND HEMORRHAGE, AND SOME OF 
THEIR SEQUENT BRAIN DISEASES CURSORILY CONSIDERED. 

Three of the most important conditions of the inter- 
cranial circulation involving the brain in grave disorder are 
embolism, thrombosis and hemorrhage, causing apoplexia, 
aphasia cerebri, epilepsia, etc., and this is a good place in 
the course to study them. All three primarily involve the 
circulatory mechanism of the encephalon and secondarily, 
more or less, the integrity of the brain texture. The two 
former ordinarily implicate the brain substance in disease 
by cutting off its blood supply and the latter by flooding 
some part of the brain with blood. 

The former two make their morbid mischief also by 
pressure of distended blood vessels, the latter does its dam- 
age by rupture of a blood vessel or vessels in the brain 
and blood -clot pressure. There is another of congestion, 
in which the circulation is involved in disturbance through 
the nervous connections of its vasomotor system which 
gives temporary symptoms somewhat like embolism and 
hemorrhage which we will consider later. 

Embolism, a plugging of a vessel, from cfi/foAos, pointed 
for plugging, c/A/faXci?, to thrust or put in, ifi/foXif a putting into, 
is the result of the lodgment of a detached clot or other float- 
ing body in the current of the circulation unable to go further, 
by reason of the narrower calibei of the blood vessel than at 

[266] 



267 

the point of departure or starting point of the clot, or embolus, 
as it is technically termed. The clot becomes arrested in 
its progress. It lodges and obstructs the circulation. It may 
be a blood clot or a number of pus cells or fat cells or a spicula 
or piece of exfoliated bone or a fibrous thrombus from a dis- 
tant inflamed or stagnant vessel. Whatever it may be, it 
has migrated along the circulation to a point distant from 
its point of origin and lodged there. Embolism or ernboly 
is embolic invagination, i, e, t ft plug nr clot has been thrust 
along a vessel till the narrow caliber of the vessel will 
permit it to go no further. 

After it has lodged it begins to make mischief, to excite 
inflammation, to cut off circulation in front of it and dam 
up circulation behind it and you have a damned bad state of 
affairs in the brain where it lodges and 1 do not speak pro- 
fanely either. The circulation is dammed where it lodges 
and this dammed condition is called embolism and the 
physician coming to the rescue would like to exclaim with 
Macbeth, *'out damned spot" and he endeavors to enforce 
the command with an all -efficient therapy of reconst 
tion, rest,, diet, digitalis, iodides, bromides, etc. 

The onset of embolism symptoms and extravasation 
symptoms are ordinarily both sudden, those of thrombosis 
are more gradual, A thrombosis is caused usually by a 
morbid slowing and vitiation of the blood as in pernicious 
anaemia or the depravity of blood following typhoid and 
other vitiated blood states, as in syphilis and after the 
grip, etc. 

Embolism, thrombosis and hemorrhage or extravasation of 
blood into the brain, are apt to produce a condition which is 
called the apopleptic state or apoplexy. But the most common 
cause of apoplexy is the rupture of a blood vessel into the 
brain, and true apoplexia cerebri, as distinguished from 




these other conditions which may cause similar symptoms 
is the result of the breaking of a blood vessel into the 
brain* It is a stroke of cerebral hemorrhage and its symp- 
toms are ordinarily more sudden and graver than the other 
conditions in violence and sequence, because in apoplexy 
from cerebral hemorrhage or true apoplexia, the blood has 
escaped into and torn its way like a cataract, through the 
delicate textures of the brain, separating, oppressing and 
destroying its psychic and motor neurones and pathways of 
motor conduction, causing coma and paralysis, where death 
does not instantly follow* Death however seldom fol- 
lows immediately on the attack, although it may take place 
in a few hours and this distinguishes it, usually, from the 
sudden death of heart paralysis. 

Apoplexia from hemorrhage, the true apoplexia, results 
from a degenerate state of the vessel walls, such as follows 
from syphilis, gout, rheumatism, excessive alcoholism, pur- 
pura hemorrhagica, the fatty degenerative states that follow 
certain infectious fevers, the degenerative vascular states of 
renal disease (uremia, etc.,), or milliary aneurisms that 
rupture, and the degenerative changes of age and heredity 
that weaken the vessel walls. Sudden congestions, the dif* 
fuse periarteritis of Charcot and Bouchard, cause vascular 
degeneration and miliary aneurisms that rupture. They 
are a most frequent cause of apoplexy, which is also excited 
and precipitated by violent emotions, mental shock or sud- 
den physical exertion* 

Apoplexia derives its name from the fact of its being a sud» 
den stroke or seizure, from the Greek (cwiwA^co, airvwkrpjvu* t 
to strike down). It is always sudden in its onset but not always 
complete in its symptoms, from the beginning. It is usually 
characterized by sudden seizure and coma. The very nature 
of its cause, the pouring out of blood into the delicate 



269 

meshes of the brain, accounts for the sudden coming on of 
coma. It thus resembles epilepsy in its onset, for it some- 
times also, when the middle cerebral artery in its cortical 
motor area is ruptured, shows convulsions as one of its 
symptoms. When it does this it is very like epilepsy for 
awhile. But if you wait awhile the epileptic will recover, 
say in half an hour or a little more or less time. The apo- 
pleptic will not. His symptoms will deepen. 

There is also another exceptional form of apoplexy 
which somewhat resembles, but faintly, for a little while 
an epileptoid seizure. It is called ingravescent apoplexia. 
The patient has vertigo but not entire loss of consciousness, 
resembling a vertiginous epileptic seizure. He has no con- 
vulsions. Wait a little while here and you can make your 
diagnosis easily. For the patient may complain of head- 
ache and vomit. He will have hemiplegia and hemianes- 
thesia after the time for your epileptic to recover. 

Before the day is over and after your epileptic shall 
have recovered and gone about his way, the coma of in- 
gravescent apoplexia, first beginning in stupidity, will have 
set in and neither nitrite of amyl nor time will arouse your 
patient from it, for he is going to die of a rupture of a 
branch of the lenticular artery into the corpus striatum prob- 
ably near the external capsule and this blood is going to 
find its way into the lateral ventricle, may be, and kill your 
patient in the course of a few days, not more than five or 
six. Be careful of your prognosis in apoplexia, even though 
your patient be conscious in the beginning and the grave 
symptoms only come on gradually. 

Examine Edinger's beautiful illustrations of lesions of 
apoplexia and the investigation will make you cautious as 
to prognostication when blood gets in among the neurones 
and commissural and projection fibres of the brain. Yet 



270 

apopleptics recover and recover quite often after the first 
attack if they are judiciously handled and have not been 
injudiciously dosed with alcoholic stimulants in the begin* 
ning, so long as they can swallow. Ingravescent apoplexia 
begins out toward the external capsule of the corpus stri- 
atum and works inward. Symptoms of lesion of the in- 
ternal capsule vary according to the location of the lesion 
in the anterior or posterior portion. The capsule is never 
implicated alone to the exclusion of the nuclei in extrav- 
asation. 

If it were possible to restrict the infusion of blood to 
the anterior limb of the internal capsule we would have no 
marked symptoms. When you have the ordinary hemi- 
plegia of an ordinary apoplexia the blood extravasatei is 
pressing on the upper and anterior two-thirds of the 
posterior limb or the posterior portion of the anterior two- 
thirds or both. The leg is most involved, the hemorrhage 
is chiefly in the posterior portion of the anterior two-thirds. 
But both thigh and leg and arms on the opposite side are 
usually involved. 

The hemonhage of apoplexia may be in the cortex or 
any part of the brain but it is usually in the corpus stri- 
atum and lateral ventricles, in the sylvan fissure or in the 
pons and fourth ventricle. There is also sometimes a 
pseudo or spurious apoplexia causing hemiplegia, coma and 
death from pure congestion of the brain. The older writers 
reported such cases, demonstrating post-mortem diffuse 
hyperemia. 

Hemorrhage into the pons is a grave affair, usually in- 
volving the eye and throat muscles, sometimes causing con- 
vulsions. The temperature runs high, the respiration becomes 
slow and otherwise disturbed, the patient swallows badly, has 
crossed paralysis and bilateral and unilateral limb paralysis 



271 

and sometimes bilateral paralysis. The fourth ventricle is 
liable to become gravely implicated and death to follow. 

The fourth ventricle is also often involved in cerebellar 
apoplexy and the patient has coma, and the respiration may 
suffer as in pontal hemorrhage. The hemiplegia of apoplexia 
is ordinarily not on the same side as the lesion, but may 
be here. In pontal hemorrhage certain nerves will aid in the 
diagnosis. In its gray substance are the nuclei of the sixth, 
seventh and motor branches of the fifth cranial nerves and 
fronting the pons near the median line, on the inner border 
of the crus cerebri, is the third nerve, while on the outer 
margin of the crus, where the pons overlaps it, emerges 
the fourth nerve, near where the fifth nerve comes out of 
the pons. 

Hemorrhage into the medulla causes symptoms similar 
to those of bulbar paralysis and often death in a short 
time. The fourth ventricle is likely to be involved, causing 
slowed respirations and slowness of the circulation shows 
medulla hemorrhage involvement also. 

Cerebral hemorrhage as you see may occur in any 
part of the brain and so may embolism and thrombosis and 
those aneurisms or abnormal distensions with destructions of 
the inner coats or intima of the arteries which form those 
favorite seats of rupture to which I have referred. Wherever 
there are blood vessels to break or small enough to stop a 
floating plug or diseased enough to arrest the circulation 
and cause the blood to coagulate and its fibrine to adhere 
to the vessel walls, there you may have these different 
destructive diseases of the brain in the order named, name- 
ly: hemorrhage or apoplexy, embolism or a plugged up 
brain artery and its consequences and that other condition 
like unto embolism, which we call thrombosis; like em- 
bolism in its effects on the brain, but unlike it in the way 



272 

it comes on. Thrombosis comes on slowly because it is a 
disease connected with a vessel wall or a slow blood cur- 
rent that comes on slowly and makes its mischief at its home, 
i. e. t at the place of its formation and development. The 
thrombus, which is the adherent clot on the vessel wall, is 
apt to gradually widen out and more and more obstruct the 
circulation. It may be likened to a Mississippi River sand- 
bar or to a dead tree that has fallen from the bank which 
at first makes a small obstruction to the channel but, by 
gradual accretions, the obstruction enlarges until the natural 
channel of the river is no longer navigable, when the gov- 
ernment employs the surgery of the dredge boat to re- 
move the obstruction and clear the channel for a freer 
circulation in this great artery of our inland mid-state com- 
merce. The thrombus is a stationary snag that has grown 
out at the spot where it has first formed and has done or is 
doing all its harm in its own home. It may be a sedimentary 
deposit from the blood, or the fire of an inflammation of vein 
or artery may b-* lodging its debris there. This condition of 
affairs, the thing itself, with the neighboring morbid condi- 
tions created by it, is called thrombosis and thrombosis of 
the brain often causes a crisis in a man or woman's life. 

The embolus acts differently. Though comparatively 
harmless at the spot where it has developed, a little clot of 
fibrine from the margin of a heart valve or slight phlebitis 
of the leg for instance, when it goes away from its home and 
lodges and it there suddenly makes trouble, often far away 
from its place of origin. It gets into the smaller arteries of the 
delicate regions of the brain and disregarding the physio- 
logical porprieties, plugs one of them up; the speech center 
branch of the middle cerebral, for example, ( the inferior 
frontal branch of Broca's convolution), and the neighborhood 
is speechless; aphasia results; or it gets into another branch 



273 

of this same important middle cerebral artery, going to the 
lenticular nucleus and plugs up the artery that Charcot 
called the artery of cerebral hemorrhage because it was so 
commonly the seat of rupture and it there causes a condi- 
tion like that of true cerebral apoplexy, viz. : a sudden 
stroke of coma with paralysis of the opposite side. Although 
all three of these conditions of the brain may exceptionally 
take place wherever there are blood vessels to rupture or 
plug or to become thrombotically obstructed. The most com- 
mon seat of apopleptic hemorrhage is in the Vartere de V hem- 
orrhage cerebral, as M. Charcot, the distinguished immortal 
savant of Paris, has named and placed it. The favorite seat 
of cerebral embolism is also in some branch of the middle 
cerebral and usually in the first or inferior frontal branch to 
Broca's convolution and the locality of thrombosis is preferably 
in the cerebral sinuses and veins of the lower extremities. 
Cerebral embolism is more common in the Sylvian 
artery of the left side than elsewhere in the brain, causing 
that interesting condition called aphasia by which the ca- 
pacity to formulate and comprehend speech or word character 
ideas, is thereby impaired or destroyed. This site of lodg- 
ment for the embolic clot floating in the current of the 
circulation is selected by the embol.s because the vis a tergo 
of the blood, the force of the circulation from behind, because 
the force of the heatf impulses drives it there more readily. 
The carotid artery on the left side leaves the aorta in a 
straighter line upwards on this side than on the right side. 
The carotid on the right side, as you see by reference to 
the plate on the wall, comes off from the artena innom- 
inata at a right angle or nearly so. It is therefore easier 
for an embolus to be driven into the left than into the 
right carotid, and having ^ot there it goes on till it encoun- 
ters a diameter in the vessel walls too narrow to permit it 




to pass. It usually goes to the first branch of the Sylvian, 
the one that leads to Broca's convolution or the Broca area 
of the third frontal convolution and either lodges at the 
bifurcation or stops a little way within one or the other of 
its branches. When the clot lodges, it clogs up the artery 
as suddenly as a rupture opens in hemorrhage and the first 
symptoms may be very like those of sanguineous rupture 
apoplexy, viz. : sudden coma and hemiplegia, but as the coma 
passes away and the hemiplegia mitigates some, perhaps, you 
find aphasia revealed. The patient can move his voice muscles, 
lips and tongue, but cannot speak. But this entire middle 
cerebral or Sylvian fissure artery is an exceedingly important 
artery for you to consider. Besides sending on the left 
side branches that sustain the integrity of the speech cen- 
ter in health, and similar branches to the corresponding but 
ordinarily latent or inactive branches on the opposite side, 
it supplies the central cortical psychomotor areas of both m 
sides of the brain, the cortical auditory centers with theirs 
nutrition and has even something to do in the way ot^ 
nourishing the visual areas of the brain. The middle cer — 
ebral artery is in fact the most widely distributed of th»- 
three main or upper cerebral end arteries. 

Of the two other cerebrals, as we have said in a piv 
vious lecture, which it will do you no harm if we repeal 
the anterior cerebrals supply chiefly t|ie corpus callosum a 
the anterior and mesial aspects of its abutting convolutio 
the first and second frontal, and paracentral lobule a 
precuneus. The posteriors supply the occipital and tempor 
lobes, the cuneus and the crus cerebri of either side a 
send a branch to the optic thalmus. 

There is an absence of free anastomosis between fc_ ~* ic 
branches of the cerebral system arteries which go to t * v 
cortex and those which go to the basal ganglia, but wl-» «?a 





275 



the carotid is ligated on one side a sufficient anastomosis 
tardily takes place, if the patient recovers from the opera- 
tion, as he often does, to re-establish the genera) circula- 
tion of the brain. 

This shows that anastomosis may become more com- 
plete under stress than some observers have asserted in 
the discussion of what they have termed the end arteries 
of the brain's circulation. The basal ganglia and the cortex 
arteries do not anastomose. 

Hemorrhage into a ventricle usually means speedy 
death. Into the fourth ventricle and iter and from it to the 
third it is always fatal. Hemorrhage into the pontal and 
medulla area leads usually to a tardier but no less certain 
death. I have seen death occasionally averted where the 
fourth ventricle was not involved. In the corpus striatum 
more hopeful and if the bleeding be in the cortex, in 
the Rolandic fissure area, you may have convulsions, but the 
outcome is the most hopeful of all, especially after a first 
attack. The same is true of embolism there. Cerebral 
thrombosis is always of grave import. An ultimate danger 
from rupture, embolism, and thrombosis is cerebral softening. 
A cursory glance again at the remaining brain circula- 
tion may aid your reflections on the subjects of embolism, 
thrombosis and hemorrhage. 

The posterior inferior cerebellar arteries sometimes 
coming from the basilar, but more often from the vertebral 
and going to the under surface of the cerebellum, divide 
there into two branches, one branch going to the fourth 
ventricle, the other between the cerebellar hemispheres. 
Of the branches of the basilar, one goes to the internal ear 
on each side, one goes to the anterior inferior portion of 
the cerebellum, supplying its front and lower surfaces and 
blending with other cerebellar arteries. Superior cerebellar 




276 

arteries come off also from the basilar and go to the upper 
surface of the cerebellum and anastomose with the inferior 
cerebellar, going also to the pineal body, the valve of 
Vieussens and the T velum interpositum. The posterior 
cerebral arteries are two terminal branches of the basilar, 
following the cranial nerve, winding round the crura cerebri 
and distributing themselves to the posterior cerebral lobes, 
dividing there into many branches and anastomosing with 
the anterior and middle cerebral. They receive communi- 
cating arteries from the internal carotids, supplying the 
posterior perforated space and the small posterioi 
artery which goes to the velum interpositum and choroid 
plexus. 

These conditions of the plugged vessels and basilar or 
obstructed vessels, causing symptoms so much like those 
resulting from extravasation of blood into the brain, 
may be called the embolic or thrombotic, hemorrhagic or 
apoplectic equivalents, just as the premonitory symptoms, 
the forewarning transient vertigos with motor weakness and 
heaviness and altered sensations in hand or foot or tongue 
are called symptomatic epileptic equivalents, sometimes. 

Disturbances of this kind should attract your attention 
and receive your treatment. They indicate varying states 
of blood pressure in the brain and should be corre 
promptly, especially if your patient has reached the age of 
possible arteriole degeneracy or if by reason of syphilis or 
alcoholism or other cause you have reason to suspect ar* 
terial wall disease. Syphilis and alcoholism are the most 
common causes of apoplexy, and rheumatism is the most 
common cause of embolism. But there are other causes* 

Hemorrhage or embolism involving the hinder or lower 
part of the posterior limb of the internal capsule, besides 
the more or less one sided paralysis, would produce hem- 



277 

ianaesthesia and special sense anaesthesia or paralysis, be- 
cause the sensory fibers pass here to the opposite side of the 
body and special sense fibers passing through here would give 
hemianopsia, and eye movement disturbances would show 
that the trouble extended up to the genu of the cap- 
sule. Through it pass fibers from the cortex to the nuclei 
of the motor oculi nerves. You. would have also facial and 
taste distortions, if the facial and hypoglossal nerves were 
impinged upon. The internal capsule, remember, is a con- 
densed compact bundle or band of motor and sensory pro- 
jection fibers on their way to important business below the 
brain in the cord and if they are intercepted by a flood of 
blood or a plugged up and compressing artery, they can 
not do their work. Their messages, motor or sensory, from 
above or below can not be delivered. We shall probably 
refer to this subject again in the clinics and again perhaps 
in discussing the subject of epilepsy, which in its beginning 
is like apoplexy, for comparison, especially in its prodromal 
aura. 

Hemorrhage is more common in men than in women, 
because man dissipates more and lives more recklessly and 
less guardedly and is more exposed to the brain artery 
damaging influences of alcoholic and venereal diseases of 
the blood vessels and because his life is more strenuous 
and more irregular. From these and other causes blood vessel 
disease of the brain falls more upon man than upon woman. 

Embolism, on the contrary, is quite as common in 
woman. Its chief remote cause is rheumatism, and women 
are equally as prone to this as men. The rheumatic fever, 
and fibrinous exudates about the heart valves furnish most of 
the emboli which, dislodging and entering the current of 
the circulation, float on till they lodge again in a narrow 
artery of the brain and form the condition of cerebral em- 



278 

holism, which is a sudden suspension of the brain's func- 
tion by the migration but sudden lodging of a clot within the 
walls of one of the cerebral arteries. While true apoplexia 
or brain hemorrhage, by contrast, is a blood clot escaped as 
blood but coagulated outside of the artery among the neurones 
and neuroglia of the brain. In embolism it is the gloved 
hand, in hemorrhagic apoplexia it is the bare hand that 
gives the foudroyant stroke, as the French call it. But in 
both it is a knock out and often fatal blow, for coma is 
common and unimpaired consciousness is rare, in either 
embolism of the brain or hemorrhage. It is seldom that 
either come on gradually* The phlebites of pregnancy may 
cause fatal thrombi. 

Cerebral thrombosis though more commonly the result 
of other causes, some of which I have mentioned, espec- 
ially in women, is in men often the result of the same 
arterial condition that most frequently causes cerebral hem- 
orrhages, especially in men past middle age, viz., atheroma. 
That peculiar degenerative process diminishes the caliber 
of the cerebral blood vessels, intercepts circulation and 
causes coagulation from the blood current, especially in old 
people who show an aptitude toward blood coagulation by 
arterial wall inflammation or profound anemia. Abnormally 
sluggish circulation or inherent tendency of the fibrine of 
the blood to separate and deposit itself from any cause, and 
adhere to the vessel \v.<l! and cut off blood supply by 
occlusion and softening of the area these vessels ought to 
nourish, results in damage to the brain if the vessel dis- 
ease is there. 

Women sometimes have thrombi and thrombosis from 
depravity of the blood in the puerperal state and men and 
women have this condition of the circulation after basilar 
meningitis and both also may have it from traumatism 







279 

the head. It is always interesting, however, and often it is 
especially so to the surgeon in other parts of the body than 
the brain. Because it cuts off the life of the tissues sup- 
plied and necrosis of the part results. 

The brain may soften when its arterioles cease by throm- 
bosis, embolism, atheroma, extravasated clots or traumatic 
severance, to nourish it. A condition technically called cer- 
ebral necrosis, or cerebral malacia, or encephalo malacia, 
takes place and there is no place in such territory of the brain 
for a normally working neurone. There are none to work 
normally. They are stunned out of existence or otherwise 
destroyed. The damaged vessels, veins, venules, arterioles 
and arteries shrink, the perivascular and other lymph 
spaces enlarge. The neurones and their neuraxones and 
dendrites become macerated and lifeless, the neuroglia 
swell and yellow softening sets in. Later this area of 
softening is absorbed and may become encysted much like a 
blood clot after a hemorrhage, if the patient does not die 
from the exsanguined pressure upon the brain. Still later the 
walls which have surrounded and enclosed this clot of blood 
and this debris of neuro-vascular destruction arresting its 
further invasion and making it harmless, may become yet 
further conquered by indominably conservative nature. Its 
walls may be brought together into a narrow cicatrized 
sclerotic scar, to mark like a monument of victory over an 
invading enemy, all that remains of his once destructive 
march. Especially is this so in the brain's cortex surface, 
if more area of destruction shows in indurated pia mater 
and serous exudation beneath, atrophy and induration still 
yellowishly discolored may be seen, like the yellow flag 
which floats over the military hospital mingled with white, 
sometimes, on the field of a recent battle. 

You will remember this contest between the resisting, 



280 

rebuilding and reorganizing forces of nature in the human 
organism and its enemies, won't you? It is always on 
guard in the battle of the organism for its life. Our fore- 
fathers lauded it as the vis medicatrix naturce. 

Softening from either thrombosis, embolism or extrav- 
asation in the brain might take place less frequently had 
Nature been less conservative in her distribution of the 
blood vessels of the brain. That is had she made a com- 
plete anastomosis throughout the whole of the cerebral blood 
vessels instead of having modified communication between 
those of the cortex and the basal ganglia. But perhaps 
had she done this there might have been too much vascu- 
lar response to the play of the emotions and man might 
have had too much induced cerebral hyperemia responsive 
to intellectual or cortex excitation. What would have be- 
come of the delicate basal ganglia if they were subject 
to every varying blood flow of the emotional or passionate 
intellectual life of the gray matter of the brain? 

• Holden in his excellent anatomical description of the 
brain's circulation reminds us of the important fact, besides 
the tortuosities of the arteries and the break in the force 
of the arterial blood flow, by reason of the Willisian cir- 
cle arrangement and the arteries' passage through tortuous, 
bony canals, to get to the brain, of the spreading of the 
arterial ramifications in that very delicate membrane, the 
pia mater, as if to try the effect of their force there, before 
Nature would permit them to enter the delicate substance 
of the brain. He calls attention to the minuteness of the 
capillaries and the extreme thinness of their walls, the 
formation of the venous sinuses which do not accompany 
the arteries, the chordse Willisii in the superior longitudinal 
sinus, the absence of valves in the sinuses and the con- 
fluence of the six sinuses forming the torcular herophili at 



281 

the internal occipital protuberance. These facts of the 
cerebral circulation are important for us to remember in 
estimating the delicate brain's capacity of tolerance of its 
rushing blood; the ability of its delicately constructed 
neurones* and their connecting neuroglia under the brain's 
normal arterial blood pressure, to do the fine work of trans- 
muting impressions into emotion, motor impulses and 
thought. It is this remarkable arterial network arrange- 
ment which the great Galen, as Holden also reminds 
us, called the rete mirabili % enabling the brain to work 
composedly in its normal state amid the rush of blood 
from the carotids and vertebrals and to make that 
blood subserve the purposes of its own reconstruction 
and of receiving impressions, forming and reforming 
reflections, without being overwhelmed by the brain's 
flood of blood from the heart. This is why the delicate 
neurones of the psychic brain centers can resist so much 
of the punishment unwise man would inflict upon it by 
excessive brain stimulation and overstraining, circulation 
exciting indulgences. But the brain, notwithstanding, can- 
not endure everything man puts upon it and will not endure 
the blood pressure whirl of daily cerebral hyperemia which 
the reckless custodians of really good encephalons impose 
upon it without protest in pain or altered function, and 
surrender to the destruction of disease. The brain has a 
way of its own, crying out against the violence of the 
reckless and vicious. 




AtMromKtAM Dag«&er»tion d#r Art, omnia ri* 

• nwvchart*, k#rnpflflif In tiro* * in frtun hyaline I'rowindlon* ba«Tfffei»a imabtni tntia* 

* Vnmmmaun der Tenaodarfcm Klutlca. tnt 4 Airupbt* der Id hyilintr Dwgvnintioa ttttadtaaattt 
JlucaJa.ru ■ Adv*ntitia / SpaJtrauni iwuchet) da r Elastic* luLorna and dsr kfclLfl) daaf*MJMS 

laiimuaJatDaa. Rigraa fivaobaehtuoar 

(MiMI Nonnf u»J Lmct+) 

Section of Brain, showing Gummata. 
Original observations by M. Nonne and H. Luce. — Flautau. Jacob so* 
and Minor's Handbook of the Pathological Anatomy of th* Ntrvous Srstsms* 

FIG. 138, 




'I* 1 



Parti* *ua olntfli Gomnu la d«r Hmibuia llnmatoaylin F^rbang 
i tammtllcbaa Otfawrn 1st d** Lumen rtarfc veronal, bai a obluehH : in deal L«*»»ii d*f «*4«na 
tttwt* tttdM Mflb »»cb eiwaj Bint i«i (rotfce aiulmorperebfn* Dn Var?n*»raiuc 4*» L«m»w anaia* 
If RcrtaBMt 4#r ProllfptAtlpn d«r "infima. f*l Mrdia Had AdvrutlttJ «ud voat (>. 

ibfcdhob laflltnitcoi <l*web« - da* *« *!**« *t«ll* norh nirhf n*knMUf» IN - *#.,« 



CHAPTER XXV. 

THE ANATOMY OF THE SPINAL CORD, WITH BRIEF REFERENCE TO 
ITS MORBID STATES. 



In your dissections of the spinal cord when the arches 
of the vertebrae are sawed through and removed, the 
spinal cord comes into view. The cord does not occupy the 
entire cavity of the spinal canal. The dura mater does not 
adhere to the vertebrae clear down the canal and does not 
form their internal periosteum or endosteum as in the 
skull. Between the walls of the spinal canal formed by 
the spinal bones, and this membrane, a space intervenes, 
which is filled with soft, reddish looking fat, with watery 
cellular tissue and the ramifications of a plexus of veins. 

''The spine is remarkable for the great number of 
large and tortuous veins which ramify about it inside and 
outside the vertebral canal. These veins are the dorsi- 
spinal or posterior external veins which form a tortuous 
plexus outside the spinous, transverse and articular pro- 
cesses, and the arches of the vertebrae, communicating 
with corresponding veins above and below, ending in the 
plexus inside the vertebral canal. They join the vertebral 
veins in the cervical region, the intercostal in the dorsal, 
and the lumbar and sacral veins below." 

"The veins of the bodies of the vertebrae {venae basis 
vertebrarutn) emerge from the backs of the bodies and 

[283] 



284 

empty themselves into the transverse veins, connecting the 
two anterior longitudinal spinal veins." 

The tortuous anterior longitudinal spinal veins run the 
whole length of the spinal canal and receive opposite each 
vertebra, the venae basis vertebrarum. 

"The posterior longitudinal spinal veins run also along 
the whole length of the spinal canal." 

The anterior and posterior longitudinal spinal veins 
are situated between the spinal canal and the dura mater 
of the spinal cord, and are called the meningo-rachidian 
veins, and the medulli-spinal or proper veins of the spinal 
cord within the dura, form the fine plexiform arrange- 
ment of veins over the surfaces of the cord. They ap- 
pear so distinct that they can with difficulty be injected 
from other spinal veins. These veins discharge themselves 
through the intervertebral foramina in the several regions 
of the spine, the cervical emptying into the vertebral veins, 
the dorsal into the intercostal veins, the lumbar into the 
lumbar veins. They are not provided with valves, and 
often become congested, in spinal disease. They may be 
the seat of embolism in sluggish states of the spinal cord 
circulation and in spinal phlebitis. 

The membranes of the spinal cord are the same in 
number and continuous with those of the brain, but they 
differ from the brain membranes in their attachments. 

The dura mater of the cord is tough and fibrous, like 
that of the brain in structure, but it does not adhere to the 
bones, being separated from them by fat, loose areolar tis- 
sue, and the plexus of veins referred to. This loose arrange- 
ment or absence of attachment of the dura mater to the 
inner spinal canal wall permits the free movement of 
the vertebrae. Adhesion would impede this, neither is 
the cerebral dura mater everywhere adherent to the inner 



285 

walls of the cranium, being most markedly adherent along 
either side of the falx cerebri and great longitudinal sinus, 
where the Pacchionian bodies are mostly found in our dis- 
sections. The spinal dura mater is attached firmly above 
to the margin of the foramen magnum, and by slender tis- 
sue to the posterior common ligament, and may be traced 
downward as a sheath, as far as the second bone of the 
sacrum, from which it is prolonged as a fibrous cord to the 
coccyx, where it becomes continuous with the periosteum, 
't forms a complete canal or bag or sheath (theca) which 




-i 



V 
5 



DIAGRAM OK A TRANSVERSE SECTION THROUGH TUB SPINAL CORD AM) I In 
MEMBRANES. 

». I/iira mater. 4. Anterior root of spinal nerve, 

». Arachnoid membrane. 5k 5. Scat of »ub-arachnoid fluid. 

3. Ganglion on posterior root of ^Posterior branch of sj.in:.l nerve 

spinal nerve. /" \l V > v 7- Anterior branch of spinal nerve. 

Urr ounds loosely the spinal cord, and is relatively larger in 

e cervical and lumbar regions than in the dorsal. On 

ac h side are two openings in the dura mater for the an- 

ei "ior and posterior roots of the spinal nerves, and the mem- 

ra ne is prolenged over the trunk of each of the spinal 

er ves. These prolongations accompany the nerve only so 

ar as the intervertebral foramina, and are there bit* nded 

! *h the periosteum. The inner surface of the dura mater 

s I'ned with a smooth layer of polygonous or many-sided 

ecr eting cells, yet sometimes called the parietal layer of 

e arachnoid membrane. 



286 

If you cut through the nerves which proceed from the 
spinal cord on each side, and remove the cord with the 
dura mater entire, then slit up the dura mater along the 
middle of the front of the cord and examine the arachnoid 
membrane you will, from its anatomical structure, note that 
the functions of the dura mater of the cord are not identical 
with the encephalic dura mater since it does not here form 
internal periosteum to the bones of the spina) canal ; nor does 
it send in partitions to support the cord; and it does not split 
to form venous sinuses, as the dura does in the brain. 

The arachnoid membrane of the cord is a continuation 
from that of the brain, and is reflected over the spinal 
nerves as they pass from the cord to the apertures in the 
dura mater. This membrane invests the cord, and is in 
contact by its superficial aspect with the dura mater, there 
being an interval between them called the subdural space, 
although, in some cases, they are more or less connected by 
connective tissue bands. On its deeper surfaces it is in 
contact with the pia mater, but is loosely connected with it 
by delicate areolar tissue, so there is a considerable in- 
terval between them (sub-arachnoid space), which is occu- 
pied by a transparent, watery fluid (cerebro- spinal fluid) 
contained in the meshes of the sub-arachnoid tissues. The 
separation between the arachnoid and the pia mater varies 
in the different parts, and is greatest in the lowest part of the 
cord. 

The cerebro-spinal fluid will claim attention from you 
in practice. It amounts to one or two ounces or slightly 
more or less and makes the watery cushion of the cord to 
protect it in a measure against spinal irritating motion and 
slight concussions of brain or cord. It consists of ninety- 
eight and five-tenths per cent water and one and five- 
tenths solid matter. It distends the theca or sheath of the 



2S7 



^ord and softly cushions the cord against violence, in run- 
ning, jumping, falls, etc. An old physiological anatomist, 
*~i ^Jler by name, discovered it and another distinguished 
I 1 * l^ysiologist, Magendie, demonstrated it. He sawed away 
^I~me arches of the vertebra* of animals and, puncturing the 
^iura mater of the cord, saw jets of fluid issue from beneath 
*^"*e punctured sheath. He called this cerebrospinal fluid, 
^l~~*e cephalo-rachidian liquid. If we could get out all the 
^s.^rum of the perivascular and subarachnoid spaces we 
^l^ould find more than two ounces of this fluid. 

The spinal fluid is called cerebro-spinal fluid because it 
^Communicates through the fourth ventricle, as stated, with 
^Ine general cerebral and ventricular serum cavities and 
^^b^ith the serum of the spinal cord. 

The cerebro-spinal fluid comes into notice, especially in 
^^ arly infancy, when the fontanelles distend or flatten, ac- 
^lording to the extent of the pressure of this fluid and in spina 
^>ifida where the spinous processes do not unite at the 
V^roper time of evolution for them to come together- If you 
BDress over the fontanelles of such a child the tumor in the 
^pine will enlarge, and if you press back the distended 
'fluid from the spine, the fontanelles will swell out. If you 
confine the fluid in the head by steady uniform pressure 
smd press on the spina bifida tumor at the same time, you 
elicit symptoms of neuraxis (or cerebro-spinal axis) pressure, 
such as vertigo, or suspended consciousness, suspended 
ability to feel or move. This experiment of nature con- 
firms the results of laboratory experimentation. The cer- 
ebro-spinal fluid should be allowed to escape but sparingly 
in the therapeutic procedure of spinal puncture for cocain* 
ization of the cord. Spine puncture and cerebro-spinal 
drainage is coming into use in these days of the mar- 
velous medical advance now on and before you, for relief 



288 

in certain conditions of excessive brain or cord pressure, 
like hydrocephalus, serous apoplexy, etc., and for purposes 
of cerebo-spinal medication besides anaesthesia and for 
diagnostic purposes. We are probably on the threshold of 
a new cerebro- spinal therapy, a neuraxis cerebro-therapy. 

The cerebro-spinal fluid has indirect relation to the 
serum, occupying the perivascular spaces about the blood 
vessels of the brain and thus becomes related to states of 
pressure about the blood vessels, as we have seen, and to 
anaemia and to the healthy tone of the brain. This sub- 
ject will occupy our further attention at another time. 

To find the cerebro-spinal fluid on dissection the cord 
must be examined soon after death and before the brain 
is removed. The nerves proceeding from the cord are 
loosely surrounded by the sheath of the arachnoid. But 
this only accompanies them as far as the dura mater, where 
the two are continuous. The cerebro-spinal fluid of the 
cord communicating with that of the brain, and also with 
the general ventricular cavities and perivascular spaces has 
important neurological bearing, as we have seen in dis- 
cussing the brain's circulation. 

The pia mater of the cord immediately invests the cord 
and its protection differs in structure from that of the brain. 
It is not a membrane filled with minute arteries, but it sup- 
ports and strengthens the cord, as the dura does the brain. 
It is less vascular and more fibrous in structure and more 
adherent to the substance of the cord. It sends down thin 
folds into the anterior and posterior median fissures of the 
cord, and is prolonged upon the spinal nerves, forming their 
investing membrane or neurilemma. 

Along the anterior median fissure runs a well-marked 
fibrous band formed by the pia mater, the linea splendens. 

Below the level of the second lumbar vertebra, the pia 



289 

mater is continued as a slender filament called the filum 
terminate, or central ligament, which runs down in the mid- 
dle of the bundle of nerves (the cauda equina) into which the 
spinal cord breaks up. About the middle of the third sacral 
vertebra it becomes continuous with the dura mater of the 
cord, and is then prolonged as far as the base of the coccyx. 
The spine of the third sacral vertebra marks the level to 
which the cerebro- spinal fluid descends in the vertebral 
canal. It is supplied with nerves from the sympathetic and 
from the posterior roots of the spinal nerves. 

FIG. 140. 



4 lik 

1 


Jfl 


1 1 


L -\ i: ' 



DIAGKAM OP THE LICAMENTUM 
DENTICULATVM. 

I. Dura mater, 
a, a, a. Ligamcn turn den ticulamm. 



Theligamentumdenticulatum connects at each side of the 
cord along its whole length with triangular or dentate 
fibrous bands. This series of processes steadies and sup- 
ports the cord in its place in the spinal canal. The bases of 
these dentate bands are attached to the cord, and 
their points to the inside of the dura mater. There are 
from eighteen to twenty- two of them on each side of the 
cord and they lie between the anterior and posterior roots 
of the spinal nerves. The first process passes between the 
vertebral artery and the hypoglossal nerve; the last is 



290 

found at the termination of the cord. It is composed of fi- 
brous tissue and is covered with nucleated cells continu- 
ous with the arachnoid membrane. 

The membranes of the cord will interest you in con- 
nection with spinal meningitis or cerebro- spinal menin- 
gitis, which is an inflammatory condition, also tubercular 
meningitis, diphtheria, and the tumors of the cord. About 
all the tumors of the cord, except glioses and gliomata, 
originate in the membranes. Gliomata and glioses are 
developed from the glia tissue, called also neuroglia. Glio- 
mata are malignant. 

Neuromata and sarcomata form in the spinal nerve 
roots, brain or cord substance and cranial nerves. Gliomata, 
tubercles and sarcomata often originate in the gray matter 
or the cord. Echinococci are generally found external to 
the dura. Cysticerci are found in the brain and cord sub- 
stance sometimes. 

Lipomata are indolent, slow-growing, fatty, painless tu- 
mors often found in the skin on scalp. Their super- 
ficial existence might warrant us to suspect them to be also 
deep seated, in certain states of the nervous system. Pay 
close attention to the chair of surgery, when tumors are 
discussed there. Most tumors of the coverings of cord are 
small, of slow growth, growing by preference up or 
down the cord and beginning after an injury to the cord or 
spinal trauma, as spinal cord wounds are surgically called. 
Syphilomata and certain cancers grow rapidly. Spinal men- 
ingeal tumors lie in the cord like an egg in a nest. They 
press upon the cord slowly but do not cause the cord ab- 
sorption and may be enucleated with relief of all symptoms 
sometimes. 

Tumors external to the dura do not immediately disturb 
the cord functions for obvious reasons, connected with what 



we know of the cerebrospinal fluid and the floating of the 
cord in the spinal canal. The favorite seat of cord tumors 
is dorsal and caudal. 

The circulation of the cord will engage your study in 
connection with congestion or hyperaemia and a diminished 
blood supply or anaemia of the cord or spinal irritation* 
The circulation is also involved in inflammation of the envel- 
oping membranes or meningitis and in inflammation across 
the cord or myelitis, the columns and horns of the cord, 
will interest you in spinal paralysis and spasmodic 
states like tetanus and the scleroses, lateral spastic, and 
posterior. 

The arteries of the cord are first the anterior spinal 
arteries, which commence at the medulla oblongata, branch- 
ing from the vertebral of each side and running down the 
middle of the front of the cord. Other branches are de- 
rived from the vertebral, ascending cervical, intercostal and 
lumbar arteries, which pass through the intervertebral fora- 
mina, and assist in keeping up the size of this anterior ar- 
tery. **And the posterior spinal arteries which come also 
from the same source, vertebral, intercostal and lumbar ar- 
teries, ramify irregularly over the back of the cord." 

"The spinal arteries of the opposite sides communicate 
by numerous transverse branches along the entire length of 
the spine" on the anterior part of the bodies of the verte- 
brae, "thus resembling the arrangement of the venous 
plexuses of the cord.' 1 Accompanying are illustrations of 
the cord's circulation. The venous from Holden (Figs, 141 
and 142) and the arterial from Brissaud (Fig. 143) and by 
Cowers (Fig, 144), the latter modified by Church (Fig. 145), 

Our modern anatomists, those painstaking followers of 
the great Vesalius, who made the first human dissect- 
ion, who by their clear delineations of the spinal cord and 




292 

its relations to the spinal canal and the vertebrae that con- 
tribute to make this remarkable nerve center channel of 
protection and conduction, have enabled us to understand 
intelligently the remarkable power of resistance of the cord 
and its membranes to ordinary movements and lighter in- 
juries of the spinal column and even to what would other- 
wise prove to be very considerable shocks to the delicate 
structures of the cord. 

FIG. 141. 







The .uran^er^em of the corJ within the spinal canal, 
floating as :t were, like ah ar.atxntcal or pathological 
specimen suspended tr* -^ the neck o: a N>ttle, immersed in 
a a*ck v^r Su:J, ena^es :hc c;ri :^ swish a little back and 
tvvth arvi ::* x :n s:~e :^ <:ic w-.:!:;-:: ha.-.n^ its rj action de- 
stroyed. l>.e ier.:*:c ::;AT.cr.:\ jl< see:: :a the accom- 
|n*;V\"Ai: :**u$:-ar. * *. x:i :**.e ..vse :c ir:^ :c the ijra of the 
*v:* ; v thx* x\"o jl v *jt~Jt. *\t > .t-j c-sh:cc:3i veins, also 
Tv v >'v* - * t^.^c / ,ia *£> :-„•.— -ijlt-Tc ;c t£e ooci's dr- 
x v a: .* \ "xv? r i * >: •■*•:"**- \iT-r**5 kirc c^oservatioo 
o* ; N * .V .* .t^i *>: ,w ~a > • : c -^ 



293 

A concussion of the cord at either side, as from a sud- 
den or violent fall on the head or on the ischial and sacral 
bones, would disturb the cerebro-spinal fluid from one end 
to the other and give the delicate neurones of the cord cen- 
ters and their prolongating neuraxone or dendrite connect- 
ions, into the motor or sensory nerves, a comparatively less 
delicate shock than they now receive under Nature's kind 

FIG. 142. 




•IAGRAM OF THR MM SAL V11INS. (iRANSVERSK SF.C HON ) 

2. P<T»~«A/- >04»aX*oA/ \KAr+**/ • 

4, J^Cfe/UXA/ 



CHoLcJ«^ 



protecting anatomical safeguard. 1 say comparatively deli- 
cate shock, because of the water wall of the cerebro-spinal 
fluid and attachment of the dentate bodies of at least 
twenty of the spinal cord segments of the cord and extend- 
ing the cord's entire length. Injury to the cord from vio- 
lence is often therefore slight and microscopic, compared to 
what it might be from the same degree of violence, were 




dering capacity and marvelausly strong protective 
rangements make up Nature's marvelous mechanism as 
displayed in her building, bounding and locating of the 
spinal cord. It can be damaged by great concussion, 
but not by the slight jars and disturbances of ordi- 
nary human movements* It takes extraordinary violence 
to harm it, like falls from heights, inadvertent stepping 




295 

downward to an uncalculated depth or the momentum of a 
railway train suddenly stopping or a. head -end collision, or 
the sudden drop of an elevator or the violent jerk of it, or a 
ponderous street car's too suddenly checked momentum. 

FIG. 144. 



Ja&- 



,W 



w 



HI 



— Semi-din uraimuatic representation of the 
arteru.* of the spinal cord; AS, anterior ijilttaL 
Central arteries. — A M, anterior meillnl ; e a t be* 
tweeti the rtffht and left coram saural arteries; 
a, nnit*romotic artery, divided transversely, to 
which w bniuh jroe* fiom the commissural artery* 
which then divides into a c, anterior rornnal, and, 
me, mid-fonuial arierie*. Peripheral arteries,— 
p in, |K>- tenor medial ; p i, post -intermediate ; p e\ 
posteuor corn mil; p r, posterior radicular; p I, 
ml, a l t reginm of the posterior, middle, and 
anterior laternl branches j a r, anterior radicular. 
In the r ght half of the figure the more deeply 
■haded part indices the region supplied by the 
cent rut arteries, 



testes the region supplied 



One of the problems for you to work out, is why an 
inadvertent previously uncalculated step into mentally unmeas- 
ured depth t even though slight, should harm the cord, when 
the same step anticipated does not. Does the will regulate the 
flow of the cerebro- spinal thud to protect the cord against 
effects of the concussion, or what does take place? What 



help do the intervertebral cartilages give, and how? Does-e 
the will regulate these as it does the muscular tension oF* 
the back muscles? Is thers something like a vasomotor"* 
mechanism for the cerebro-spinal fluid channels? Worlc^ 
this problem out in your minds and tell me what you.K 
think about it at our next meeting, or later in the med- — 
ical press. 

The true nature of the tumors of the interior of ther^ 
cord is generally best diagnosticated post-mortem. We de 



FIG. 145. 




Art<rii"« <>f ilu» ^pinnl o<>rd. A S, Anterior spinal; A Af, anterior median; ee, coutrot*. 
.uii'iiioiic . .' i ■. ;ini.n..r i-ciitral ; p. interior central ; a r, anterior rwut arteries; a I, a «t trior 
iiHiiiaii l:ti> r.il . pi, jw^ifrior lalt-rnl ; /> r, posterior root artery ; or, poller u»r curnual . /♦ t, 

. Hal , p »., jvit-rior iuoIUii (molifitxl ail»»r Ober-tdii' " * * 



"%&S3$ 



tect their existence through unilateral or bilateral neuralgic 
symptoms and circumscribed hyperesthesias encircling the 
trunk hemiplegias, monoplegias, paraplegias or, if in the neck 
regions, general paralysis. Irritation at the posterior spinal 
nerve roots causes pain usually unilateral, because tumors 
are generally one-sided, at least in the beginning of their 
development. Besides pain, their extreme pressure causes 
belt lines or half belt lines of anaesthesia. Motor weakness 



297 

sets in and later spinal paralysis and spastic states appear 
and bladder and rectum functions are affected. 

The spinal cord, only from sixteen to eighteen inches 
in length in man, and a little shorter in woman, weighing 
about an ounce and suspended in the vertebral canal down 
to the second lumbar vertebra, with a swing movement in 
the spinal canal of from a half to three quarters of an 
inch, or a little more, is a source of remarkable power in 
health, a power greater than any mechanism of man's contriv- 
ance of many times its size and weight. It is also subject 
to very remarkable diseases. Like the brain, the cord's 
inflammatory diseases are congestive, anaemic, adventitious, 
hernial protusions, degenerative states, tumors, specific dis- 
ease, like tuberculosis and syphilis or toxic disease, like 
tetanus and functional states, like neurasthenia, and the 
secondary conditions of its inflammations classical in the 
sclerosis and softenings, degenerative states of the cord, 
like the ataxias or scleroses, posterior or disseminated. 

The meninges of the spinal cord, like those of the 
brain, are liable to pachymeningitis, hemorrhagic and hyper- 
trophic pachymeningitis and the pia mater to leptomeningitis. 
The substance of the cord is subject to myelitis and syrin- 
gomyelia, as the brain is to porencephaly and cerebritis. 

The circulation of the cord suffers, like that of the brain, 
from embolism, thrombosis, hemorrhage, plus and minus 
blood supply states, and the cord is subject to disorder from 
injury or deficiency of its incasing vertebrae, as in Pott's 
disease or spina bifida. 



298 



THE SPINAL CORD, AFTER QUAIN AND FERRIER 
FIG. 146. 




In A the anterior surface of the cord is shown. The anterior nerve i 
being divided on the right. In B a transverse section of the cord is exhibit- 
ed, showing the crescentic shape of the grey matter in the Interior. 1, The 
median anterior fissure. 2, Posterior median fissure. 3, Anterior lateral 
depression over which the anterior nerve roots are seen to spread. 4, Pos- 
terior lateral groove into w*ich the posterior roots are seen to sink. 

The anterior column is included between 1 and 3; the lateral colusui 
between 3 and 4; and the posterior column between 4 and 2. 

5, The anterior root. 5' in A equals the root divided. 6, The posterior 
roots, the fibers of which pass into the gaoglion 6'. 7, The united or cost- 
pound nerve. 




Section of the spinal cord after Ferrler, in the lumbar region, magnified. 
— A, The anterior column. L. The lateral column. P, Posterior column. 
I, The anterior fissure. 2 t The posterior fissure, 3, The anterior cornu 
with multipolar cells. 4, Posterior cornu the letters placed on the sub- 
stantia gelatinosa, 5, The anterior roots of the spinal nerve* 6, The 
posterior roots. 7, The anterior commissure. 8, The posterior commissure, 
9, The central canal of the spina! cord lined with epithelium. 



CHAPTER XXVI. 

NERVE CENTERS (CONTINUED). 



PSYCHO-MOTOR CENTERS— VISUAL APPARATUS CENTERS— OTHER MO- 
TOR AND REFLEX CENTERS. 

Nerve centers are somewhat shadily circumscribed re- 
gions in the nervous system made up of groups of neurones, 
as we have seen in a previous lecture, having a common 
function, to which concentric or afferent nerve influences 
travel or converge and may be there acted upon by the 
nerve center and from which efferent or eccentric impres- 
ions emerge or are sent out. If the peripheral impression 
going to a nerve center is simply transmitted into a motion 
or pain or other sensation and sent back to the point from 
which the afferent or peripheral impression originated or 
started or to some related peripheral organ, the action is 
called a reflex action, as when a smart tap below the knee 
sends up an impression afferently to the posterior col- 
umns of the spinal cord, then goes across the cord to the 
anterior motor poles or horns or cornua of the cord and 
comes back (efferently) to the knee again, as a motor im- 
pulse, making the classical knee jerk or knee phenomenon 
in healthy states of the posterior root zones of the cord, 
but which can not be elicited in posterior spinal sclerosis 
or locomotor ataxia and in that suddenly oncoming disease 
of the anterior horns called poliomyelitis, anterior or infan- 

[301] 




tite paralysis, or the essential paralysis of children, anc 
which is also absent in a similar condition of the anterior 
horns of the cord in adults. 

The reflexes are all over the body. The eye has its 
reflexes, as when a grain of dirt impinges on the eyeball 
and the eyelids wink till it is removed, or as they wink 
when we tap the supraorbital or infraorbital region over 
their respective nerves of the fifth pair emerging from the 
superior or inferior orbital foraminae. 

The nose has its reflexes or reflex starting points, as in 
sneezing, which is a medulla reflex, and there is a peculiar 
reflex or rather transmitted impression which runs over 
the body in some people when the external canal of the ear 
is tickled. The larynx and pharynx have their reflexes, as 
when coughing or swallowing are excited, the stomach as in 
vomiting, the bladder in urination, the rectum in defecation, 
the bowels in peristalsis, the genitals, the chest, the plantar 
region, the toe, the sole of the foot and so on. These re- 
flexes are really nerve center reflexes only manifested in 
these localities. But we shall recur to them again and 
more in anatomic and diagnostic detail. 

When a nerve impression is not transformed and sent 
back in motion or reflected in pain, it is often transmitted 
further along or higher up the cerehro- spinal axis, it is 
called a transmitted impression and a good deal of what is 
often inconsistently called reflex action is really of tins na- 
ture. True reflex action is usually sensation transformed into 
motion and sometimes pain with it, and sent back to the 
point of origin of sensation or near to it. Other varieties 
of what has been loosely called reflex action are really 
transmitted or sent on impressions, exciting action in some 
other point or nerve center, There is probably not so much 
pure reflex action in nervous disease as has been supposed, 



303 

but a good deal more of transmitted nerve center action 
^Pendent on physiological nervous connections made to 
actrriorbidly and reveal disease by reason of intimate, though 
S0IT *etimes distant, nervous relations as you may see, and 
study w ith diagnostic and therapeutic profit in the pain point 
tables and pain transmission of your text- books, notably, 
,n the instructive table of Dr. Allan M. Starr and Mills. 

In addition to the psychic and sympathetic system cen- 
ters, the centers of the nervous system are designated sen- 
sory centers, for the reception of sensation, motor centers 
*°* the sending out of impulses. Reflex centers at the top 
*f the reflex arc where sensory impressions are converted 
,r *to motor impulse or expression, inhibitory centers which 
1 ^hibit or arrest or prevent action that would otherwise be 
*^xire reflex movement. Motor centers are either spinal mo- 
^*Dr or brain motor, that is, psycho-motor or cortical motor 
Centers. The most important motor centers are the corti- 
cal, as they are also anatomically located highest in the cer- 
ebrospinal axis. 

Cortical centers are gray matter brain centers. They 
^tre called cortical motor centers or psycho- motor centers, 
because impulses to direct movement originate there, and 
psychic impression centers because voluntary movement 
thought, originates in them or rather starts from them. Im- 
pressions go to these psychic centers from without the brain, 
principally through the nerves of special sense as those of 
smell, taste, sight, hearing. Special touch and general sen- 
sation and impression pass up to them through and from 
the .periphery and posterior columns of the spinal cord and 
through the optic thalami, as the latter go to the spinal 
cord from the surface of the body. 

The motor centers of the brain, called psycho-motor cen- 
ters, are mostly tocated and grouped about either side of the 



304 

fissure of Rolando, in the ascending parietal, the ascending 
frontal convolution iinJ the third frontal convolution or speech 
center of Broca t the location of aphasia. Impulses from them 
outward from the corona radiata or project in fibers down- 
ward through the crura cerebri and pyramidal tracts and 
anterolateral columns of the spinal cord. 

The auditory center or cortical sensory center for the 
conscious reception and discrimination of sounds is in 
superior temporal convolution below the fissure of Sylvius 
on'either side, but probably more active in the left side like 
the speech centers, in right - handed persons, the left 
hemisphere with such persons being the specially active or 
driving side as Ferrier called it. Several subordinate dis- 
tinct or subsidiary centers are supposed to make up the au- 
ditory center, but you need not puzzle your brains with this 
matter just now. Remember that the hearing center, with 
alllits real or fancied subdivisions is located in the temporal 
region. 

The final termination of visual impression is in the oc- 
cipital lobes. Visual fibers of the optic nerves and optic 
nerve tracts conveying visual impression go to the lateral 
geniculate bodies, the anterior corpora quadrigemina, the 
pulvinar of the optic thalami, and the angular gyrus or pli 
courbe and are distributed over a great part of the occipi- 
tal lobes, Their whole area appears to be full of tight. 
Monk's slicing experiments on dogs have shown where the 
optic apparatus is normal in structure and function. The vis- 
ual center is more definitely located in the left cuneus, lin- 
gual and fusiform lobules and the angular gyrus for the ap- 
preciation of external objects, but 1 think the side of the 
brain depends on the matter of use. We may be ambiauditory 
as we are ambivisual and as we may be ambidextrous. 
Witness the once clumsy but now dextrous violinist, 



305 



^fter training, like Ole Bull, Kubelik and other skilled per- 
formers, make the world marvel at the skill of their hands 
1 *> delicacy of touch. Equal nucleal, though latent, central 
Possibilities, are in the right side of the brain , as well as 
1 »"> the left. Our brains, as yet, are only partly educated. 
There is a distinct auditory, as well as visual word 
^^ filter, by which neurologists account for some of the va- 
*~ ieties of aphasia, by which word symbols are understood 
^^nd word sounds are not and vice versa by the aphasiac 
fc^erson. The olfactory center has been located in the un- 
^^ inate gyrus, but the sense of smelt may be impaired or 
^3estroyed and anosmia may be produced by injury or disease 
^^t any of the origins of the olfactory nerve or along its 
course anteriorly or at its middle turbinate bone point of 
^distribution as in oezoena. Hyperosmia, that olfactory su- 
persensitiveness, which exists sometimes in hysteria and 
ether nervous diseases and which Alexander Pope may have 
had in mind when he referred to the possibility of one dy- 
ing of a rose in aromatic pain, may depend upon hyper - 
excitation along the distinctive course or at the brain 
origin of this nerve, as from a tumor impinging upon or a 
cerebritis or inordinate activity. 

Grouped within the medulla oblongata, not far from the 
fourth ventricle, which seems to have been assigned the 
duty by Dame Nature of providing resident centers for most 
of the cranial nerves t is located a whole colony of vital 
nerve centers. We marvel at the centers of power and in- 
fluence concentrated in the fourth ventricle. We wonder 
even more at the number and strength of the nerve centers 
of the medulla. This subject surprises us quite as much 
as the nerve force and influence carrying capacity of that 
little band of nerve strands collected and compressed, and 
carrying down from the brain through the internal capsules 




i 




,9*&&** , *™ al *' 



/*** 



"SV*» 




CHAPTER XXVI. 

NERVE CENTERS (CONTINUED). 



Psycho-motor centers— visual apparatus centers— other mo- 
tor AND REFLEX CENTERS. 

Nerve centers are somewhat shadily circumscribed re- 
gions in the nervous system made up of groups of neurones, 
as we have seen in a previous lecture, having a common 
function, to which concentric or afferent nerve influences 
travel or converge and may be there acted upon by the 
nerve center and from which efferent or eccentric impres- 
ions emerge or are sent out. If the peripheral impression 
going to a nerve center is simply transmitted into a motion 
or pain or other sensation and sent back to the point from 
which the afferent or peripheral impression originated or 
started or to some related peripheral organ, the action is 
called a reflex action, as when a smart tap below the knee 
sends up an impression afferently to the posterior col- 
umns of the spinal cord, then goes across the cord to the 
anterior motor poles or horns or cornua of the cord and 
comes back (efferently) to the knee again, as a motor im- 
pulse, making the classical knee jerk or knee phenomenon 
in healthy states of the posterior root zones of the cord, 
but which can not be elicited in posterior spinal sclerosis 
or locomotor ataxia and in that suddenly oncoming disease 
of the anterior horns called poliomyelitis, anterior or infan- 

[301] 



CHAPTER XXVII. 



THE SENSORI-MOTOR SYSTEM IN DIAGNOSIS— THE REFLEXES. 



Bioplasm is all about us in animated organism respond- 
ing in reflex action, to the impression of environment and 
the unanswered question, which it suggests, "what is life?" 
recurs to us as it did to Pilate and the philosophers of old. 
Lional Beall, applying the term bioplasm of life to the pro- 
toplasm through which animate movements appear to us, 
has not answered the question to the satisfaction of the 
scientific world. Will you in your studies of neuro-biology, 
endeavor to solve it for the enlightenment of mankind and 
the satisfaction of the soul's longing for clearer light on 
the subject? Man still asks the question. 

The great law of nerve reflex action responsive to per- 
ipheral impression, that transforms the knee-tap below the 
patella, for example, into a knee-jerk; that causes response 
with a gentle inspiration to the presence in the bronchi and 
pulmonary air cells of a congenial breath of air and an ex- 
piration to the presence of carbonic acid, generated by the 
pulmonary air change, or in cough or spasm to an uncon- 
genial breeze, or gas or other irritation; that makes the 
sneeze similarly responsive, or the strangling effort at ex- 
pulsion of food or water going down the wrong way, into 
the trachea instead of the gullet; that moves the bowels 
or bladder or regulates the sphincter; that causes the face 

[308] 



309 

tc * smile with joy or mantles it with sadness, responsive to 
a ^v^oice or written word; that makes the pupil move to 

* ^tit or to the withdrawal of light in darkness; that moves 
^*^*^ eyelids, lights or dims, moistens or drys the eyes; 
"1 inches the cheek with fear or suffuses them with 
"Ivjshes; gives the fierce glare of anger or the expressions 
c> ^ r vengeance, despair or hope; that causes weeping, laugh - 
^^t or tears and all the different facial expressions of the 

" N - r trying moods and emotions of the mind. That makes 

"Soft eyes look love to eyes that speak again," 

*" ^fleeting love in smiles of reciprocal joy; that show sad- 
ness in tears, joy in mirthful laughter and shame in the 
downcast look, are all psycho- neural reflex phenomena. 

Psychic reflection flashes back the wit responsive to 

other psychic impression that is "wont to set the table in 

ai roar." It tunes the voice of the warbling nightingale and 

excites response, in the human brain and related vocal cords 

to spellbinding oratory, swaying the multitude, or to 

Poesy's enraptured song, flying on the wings of Pegasus, far 

beyond the ordinary psychic dwelling places of man. Even 

the value of the bath Diana takes at the fountain, besides 

its purification of the skin, which fills her body with the glow 

of health, comes through a vaso- motor reflex blush of the 

cutaneous capillaries and nervous internal stimulation. 

Poesy, song, oratory and the entrancing influence of 
truth and the wondrous power and revelations of science 
are shown in the full knowledge of the physiological signifi- 
cance of reflex function. As this knowledge has come and 
is yet further coming to us, it is bringing us nearer and 
nearer to that knowledge which is yet to reveal the still 
concealed mysteries of organic life. 

And our friends, the great, studious, painstaking cytolo- 



310 

gists and cyto-chemists and indefatigable microscopists 
will yet show to us through their great labors and re- 
searches, the full truth, not dimly and darkly, as we now 
see, as through an obscuring glass, but in the full glare of 
the coming sunshine of an onmarching cytological, neurolog- 
ical and psychological science. 

Study the reflexes of organic life so far as they are 
now revealed and search further for others. The final rev- 
elation of the now hidden mysteries of life are the possi- 
bilities of their unfolding knowledge. It brings the sper- 
matozoa and the ova together in the consummation of "two 
souls with but a single thought, two hearts that beat as 
one" and by it new lives are born. It presides over the 
quickening of the unborn foetus in utero and causes the 
child to begin its later search for the pabulum of life in 
the lacteal fluid of the generous mammary gland of the 
mother. When evolution is complete at puberty it "causes 
the passionate heart of man to enter the breast of the wild 
•dreaming boy" and the mind of the maiden at maturity to 
fill and her heart to throb with new emotion. It translates 
instinct into function and heredity into physiological or 
pathological action. The philosophers of science are yet 
puzzled to find the boundaries of reflex and free will, so 
closely allied is reflex with apparent will power. "The 
chemical stimulation of food in the mouth will in certain 
animals set the jaws and mouth into masticatory action." 

A bee's mouth will suck honey after its head has been 
cut from the body. "Other stimulations" notes Edinger 
"will cause a forward movement of the head and such move- 
ment can be of sufficient force to lead to very serious re- 
sults. Thus a planaria on which two heads have been 
bred will sometimes tear its own body in the effort of mov- 
ing each head separately." (Loeb). Two arms of a star 



311 

**ssti sqjeezed into the small neck of a bottle, will drag the 

^^hole body after them, although the creature must inevi- 

*sibly perish. The head part of the lob-worm, separated 

^rom the body and covered with sand on the slate, will 

* immediately start a boring movement, and the lower part 

of a bee when cut from the rest of the body will apply the 

^ting, if interfered with. This is evidently the mechanical 

Result of a particular stimulation and has nothing in com- 

TOon with anger, vengeance, venom or self-defense. 

"It is a well-known fact that frogs couple in the spring 
time and no knife can part them. " Earlier experiments by 
Golz have shown that at the coupling time the skin of the 
female and even that of the male, even though they be 
dead, if stuffed with ova, gives rise to the reflex action of 
embracing as soon as it is brought into contact with the 
inner side of the frog's feet. We might cut up the frog from 
behind up to the cervical cord, or crush it from the head down- 
ward, the result will remain the same; i. e. t the ring formed 
by the cervical cord and the two arms, even when entirely 
separated from the rest of the body, will continue in the 
position and action of coupling frogs. " (Edinger). 

Search for and seizing of food can be ascribed directly 
to reflex movements. The frog does not search for the 
worm, but the moving worm when sufficiently perceived by 
eye and ear, sets into motion the process ot catching it on 
the frog's part. This can be easily perceived in places 
where animals are kept in a cool temperature, and pro- 
cesses run their courses slowly. The well-known fact that 
lower animals mostly feed on moving objects, is thus ex- 
plained. It is easy to deceive them by setting objects in 
motion. Artificial bait fishing is based on the same prin- 
ciple^* 

♦Edinger In April Monist. 1901. 



312 

While independent reflex mechanisms are in the viscera, 
skin, and probably in the forebrain also, the medulla and 
the cord below are preeminently their seat. The life of 
the spine is in its reflexes and much of all organic life else- 
where in the cerebro-spinal axis is. Gentlemen, reflect 
well on the reflexes of animal life, for in thenrf you may 
find much of the philosophy of life, and much to aid you 
in the intelligent understanding and practice of your pro- 
fession. 

Suitably recipient nerve endings receive, and conduct- 
ing or afferent nerves carry peripheral impressions to the 
posterior columns of the cord or directly to the brain. If 
the impression goes to a posterior center in the rord and is 
passed over to the anterior columns and transform, d into 
motion without the intervention of the brain, the whole phe- 
nomenon, sensation and involuntary motion resulting, is 
called a spinal reflex — and these reflexes may be either physi- 
ological (i. e, t natural and normal) or pathological (f. e., not 
natural but abnormal to particular nerve arcs). For exciting a 
normal reflex a sudden, generally a surprise impression and a 
healthy nerve center are requisite. An abnormal reflex 
generally depends on central morbid irritability or commenc- 
ing degeneration. The reflex arc is the track of sensation 
from the distal end of a sensory nerve to the cord center, 
passed over across the cord from posterior to anterior horns 
and there converted into sudden movement from central tc 
distal end of motor nerve, completing the reflex arc. 



313 



REFLEX AND INHIBITORY CENTERS. 



FIG. 149 




Scheme of peripheral spinal sensory neurone showing the peripheral 
process, d, extending to a peripheral sensory surface D and a central axone 
c, entering the spinal cord through the dorsal root of a spinal nerve, there 
bifurcating at* into an ascending and a descending limb which give off num- 
erous collaterals. The cell boJy is shown in the spinal ganglion G. 

Other neurones are shown schematically high up in the gray cortex of 
the brain at g, to which the arrow points, receiving the upward going peri- 
phero-spinal sensation and at A to a with the downward pointing arrow 
between, showing the origin and outflow of a motor impulse from a cortex 
neurone group to its spinal cord ending at b, and its final peripheral ex- 
pression at C. The whole showing impression from environing influence 
carried afferently to the brain and sent back from a psycho-motor center to 
to environment again in active impulse. X represents the sensory impulse 
as having undergone a modifying or inhibitory change through contact with 
cortex inhibitory influence, slightly modified in description. (After Ramon 
y Cajal, description modified.) 



314 

The phenomena of a reflex, therefore, is a peripheral 
sensation transmuted into responsive motion. 

Reflexes or jerks have been divided into skin or super- 
ficial reflexes and tendon or muscle or deep and visceral re- 
flexes and into organic or physiological and pathological. 
Some authors, Gowers for instance, do not consider the 
tendon jerks as true reflexes, but 1 so regard them and 
think they are quite as emphatically entitled to be consid- 
ered as true reflexes as the skin reflex phenomena. All re- 
flexes are dependent on spinal cord or sympathetic or gang- 
lionic or brain central connections, and I see no need of 
any confusing differentiation, since the principle of their dis- 
play is the same, namely: an impression made at one end 
of a sensory nerve exciting a corresponding motor response 
through a connecting motor nerve and central communica- 
tion. The so-called superficial reflexes are those of the 
foot (dorsal flexion), and the withdrawal that results from 
tickling or making a sudden painful or cold or hot impres- 
sion on the sole of the foot, the abdominal, etc. Every 
one knows how, in sleep, the foot will flex and the leg 
draw up when the sleeper. is tickled or scratched on the 
sole of his foot. The reflex of the testicles or cremasteric 
reflex, by which the testicle is made to draw up by pinch- 
ing or applying electricity to the inner side of the thigh are 
other skin reflexes so-called. They are organic reflexes, 
though not always so termed by authors, because they be- 
long physiologically to the organism in health like the knee, 
or quadriceps extensor femoris tendon reflex, as it is some- 
times otherwise lengthily termed. There are many other 
organic reflexes which are active in health and impaired in 
disease. 

The true organic reflexes are those which are necessary 
to some physiological function of the organism like those of 



315 

the stomach and bowels in peristalsis and the contractions 
that promote the downward movements of the intestinal in- 
gesta and excreta, or like those of the aesophagus.and the 
closure of the epiglottis in swallowing a drink or a bolus 
of food, the rhythmical movements of the lungs and heart, 
the sneezing excited by a sternutatory, the coughing of a 
bronchial irritation or the blinking of an irritated eye, (an 
^ugenblick) , a movement so rapid and brief and sure that 
the Germans have coined this unerring function into a most 
expressive phrase significant of celerity and certainty. 

The rectal reflex through which defecation is per- 
formed and by which the involuntary discharges of destruc- 
tive brain and cord disease, (dysentery and diarrhoea), some- 
times occur when the inhibitory brain centers and fibers com- 
ing down the cord from them in the brain are exhausted 
or spinal cord communication from the brain down- 
ward is intercepted or destroyed, as in spinal injury, coma, 
some states of delirium, or when the patient is in articulo 
mottis or the condition of death, just following the death 
stroke. It is the same with the retlex controlling the urin- 
ary excretion, but the bladder retlex generally contracts the 
sphincters under withdrawal of the cerebral inhibitions, ex- 
cept when bladder distension is very great, unless 
there is a conjoint general convulsive condition, as in epi- 
lepsia. 

The antagonizing reflexes of the sphincters and the 
bladder fundus, the preponderating weakness of the one 
over the other and the state of the brain inhibitions, ex- 
plain the differing bladder phenomena of urinary retention 
or expulsion. 

The enuresis of childhood is a weakening of bladder 
sphincter control reflex conjoined with general nervous debil- 
ity, which is irritability, which causes the bladder to contract 



316 

on its contents when it is full and expel them, while the 
inhibitions are off guard during profound sleep. There are 
also a perineal, genital, genesiac, virile and many muscular 
tendon reflexes which are normal. Others appear only when 
there is disease. 

The lubo-sacral plexus of nerves; the fifth lumbar and 
the first, second, third, fourth and fifth sacral nerves presides 
over the bladder, rectal, sexual, indudingthe cremasteric and 
virile reflexes, and over the reflex of the perineum and the 
quivering nates that tremble when they are slapped. Thus 
you see the whole subject presents interesting aspects to 
physiologist, pathologist and clinician. The abdominal 
and scapular reflexes are made possible through the dorsal 
nerve supply— sensory and motor — distributed to the skin 
and muscles of the thorax and abdomen. The pudic nerve, 
in its reflex relations, as I shall show you later, is exceed- 
ingly important and likewise the vagus. 

The deep or tendon reflexes, the clonus and other con- 
tractions, the paradoxical contraction of Westphal, the pu- 
pillary reflexes, including the Argyll -Robertson pupil, the 
nerve reactions especially of degeneration under electric 
stimulation and the conditions and terms of disturbed sen- 
sibility will engage our attention again in subsequent lec- 
tures. 

1 give you on the board a simple schematic diagram 
of the reflex arc with an imaginary line of inhibitory con- 
duction from the brain to the center or the reflex arc. I 
stop here purposely in order not to embarrass your under- 
standing of the wonderful phenomenon of reflex which is 
in reality not quite so simple as thus far appears, though, 
so far as this lecture has proceeded, I have been scrupu- 
lously correct. 

But there is another and very important feature to the 



317 

physiology of the spinal reflexes and the cerebral too, in 
fact, which often has valuable pathological and diagnostic 
significance, and that is the fact that the spinal reflex re- 
sponses to peripheral irritation are often exaggerated, some- 
times very greatly exaggerated by pathological conditions of 
the brain and spinal cord, as apoplexia, chorea, anterolat- 
eral sclerosis, the late state of the epileptic paroxysm, hys- 
teria, neurasthenia and emotional and debilitated states of 
the brain, which goes to confirm the view that there are 
also downward conducting nerve paths from the brain which 
serve to intensify the spinal reflexes as well as those which 
serve to restrain them, so that as the reflexes are said to 
be reinforced or exaggerated by restraining or diverting the 
cerebral inhibitions, they are also intensified by certain ex- 
citable states of the brain as well as the cord. In that para- 
doxical disease, hysteria, so much like the sex in which it 
is most frequently manifest, when they are neuropathic, 

11 Variable as the shade 
By the light quivering aspen made," 

you will find many reflex contradictions; intensification 
in one direction and impairment or lost reflex in another. 
Intense feeling in one side and lost sensation in another, 
just as alternating psychical states rapidly succeed one 
another, as shown in the weeping that succeeds laughter 
and vice versa during a paroxysm. So that we must now 
make another diagram in order to be perfectly plain on this 
subject. 

The emotions which give rise to erectio penilis or which 
stimulate the bulbo-cavernous or virile reflex center in the 
cord from the brain cortex, restraining or causing urinary 
ejaculation and defecation or the voluntary influence, which 
increases as well as resists them, are confirmatory of rein- 



318 

forcing influences and communications with spinal reflex 
centers. Education is the upbuilding and culture of the in- 
hibiting neurones of the cortex that regulate the lower re- 
flex and motor neurone centers of the brain and cord. 

There are many important reflexes not yet recorded. 
The virile is one which 1 have recently recorded in the lit- 
erature and the lately recorded bulbo-cavernous, by Onan- 
off, is another of the recent reflex records quite similar to 
and associated with it. 

It presides over the virile erection and when 1 first made 
communication on the subject at about the same time that 
Onanoff did in France, 1 thought it was the same, but it 
is not precisely. It is a downward jerk of the organ, not 
a twitch or an erection. 

The following are the other principal reflexes: 

The patellar tendon or quadriceps extensor femoris, 
vastus intima and sub-crurens muscle reflex caused by 
briskly and suddenly tapping the tendon patellae just below 
the knee cap while the legs are crossed or dangling loose 
from a table. This is the typical reflex. The others are 
like unto it. 

Next we have the ankle reflex and ankle or foot clonus. 

The wrist reflex, the hamstring muscle and tendon re- 
flex behind the knee, a reflex well known to school boys, 
elicited by striking the hamstring tendons while the man is 
standing upright. 

The triceps tendon reflex or elbow jerk. The biceps re- 
flex. The shoulder and scapular reflexes. 

The jaw jerk or chin reflex. 

The pupillary and ciliary reflexes. 

The pectoral reflexes. 

The plantar reflexes. 

The lesser toe extensor reflexes. 

The great toe extensor reflexes. 



319 

The reverse extensor response of the great toe or sign 
'* 13abinski, said to indicate lateral sclerosis of the cord. 

The cremasteric and scrotal reflex. 

The penile and virile reflex. 

The abdominal and epigastric reflexes or rectus abdom- 
*"* ^lis reflexes. 

The erector spinal reflex. 

The scapular reflex. 

The palmar reflex (not easily elicited in the waking 
^tate). 

The conjunctival or eyelid retinal reflex to light and 
***«chanical irritation. 

The retino- papillary reflexes. 

The skin pupil reflex from irritating skin of anterior 
lateral side of neck, cheek or chin. 

The cilio-spinal pupillary reflex from irritating cilio- 
spinal center of cervical cord. 

The reaction of degeneration reflex ending in lost 
reflex. 

Then there are tremors of muscle, tongue or extremi- 
ties indicating wasting, exhaustion and degeneration of muscles 
and choreae movements and tics, all dependent upon disturbance 
of the reflex function, as likewise are certain spastic states, 
important to consider in diagnosis. 

There are many more reflexes yet to be discovered. 
Look for them gentlemen, and when you find them, study 
their significance. Make a record of your findings and your 
names will become famous in diagnostic neurology. 

The flexor digital and thumb reflexes are other re- 
flexes to which I call your attention, though they are not 
yet in the literature. 



320 

ADDENDUM. 

BABINSKI'S SIGN.— H. Schneider has found that, while 
it is practically true, nevertheless the assumption that the 
presence of Babinski's phenomenon indicates a lesion of 
the pyramidal tracts is open to certain theoretical objections. 
The normal response to stimulation of the sole of the foot 
consists of two reflexes having different origins. One of 
these, plantar flexion on slight stimulation, is a cortical 
reflex, while the other, dorsal flexion of the toes, with asso- 
ciated movement of the leg, is evoked by strong stimuli 
and is of spinal origin. Babinski's sign is present when 
slight irritation is sufficient to produce dorsal flexion without 
the occurrence of plantar flexion, and is always due to gen- 
eral increase in reflex excitability. It may be caused in 
two ways: first, through a break in the pyramidal tracts, 
whereby the cerebral reflexes are cut off (which is the true 
Babinski), or, secondly, in conditions of increased spinal 
activity (e.g. strychnine poisoning), or of decreased cere- 
bral excitability (stupor), when the dynamic excess of the 
spinal response suppresses the cerebral reflex and simulates 
the true condition. — Berliner klinische IVochenschrift in 
Kansas City Med. hid. Lan. 



323 

The reaction of degeneration, which we have already 

l ^cr hissed somewhat, is a neuro- muscular phenomenon de- 

^^J^cJent upon the relation of the central and sensory motor 

ri ^ r V/ous system to the muscles involved, and the muscles are 

^^tally involved in atrophic degeneration, too, as well as 

^^ connecting nervous system. Progressive myatrophy or 

^*v* ocular atrophy is the nervous system disease, in which 

*"*i:s phenomenon is most typically displayed. It is, in fact, 

Progressive neuro-myatrophy. Rapid degeneration and 

•^^ reaction to electricity characterize Wallerian degener- 

^ion and its reaction to degeneration. 

Degeneration of the pyramidal tracts follows degenera- 
l Ve nerve change at the top or the pyramids, as in the en- 
^"^psular or destructive inter-ventricular extravasation or 
^V*philitic or atheromatous cerebral artery degeneration 
^*ld destruction of brain. According to Russell, if the vermis 
**f the cerebellum is removed, the vestiform bodies degen- 
erate. Von Gudden removed the eye of rabbits at birth, 
and afterwards found their optic chiasma and optic tracts 
degenerated. Nissl showed alterations in neurones after cut- 
ting off their neuraxones. 

As we have already seen muscles and nerves in cer- 
tain diseases of the nervous system respond differently from 
the normal reaction to electrical impression. Their impres- 
sion excitability to this stimulation is changed both in quan- 
tity and quality. The muscular contractions vary in in- 
tensity, in promptness and in character, and after a time 
they cease to respond at all. Irritability," responsive to 
electrical stimulation varies here remarkably, as the reflex 
responses in various parts of the body differ to percussional 
impression, being unduly rapid jerks, slow or irregular. 
Usually when the reflexes respond in exaggerated manner 
to the sharp stroke of the pleximeter or hand, the muscles 



324 

respond or fail to respond likewise to electrical excitation, 
as they do in chorea, tetanus, antero- lateral sclerosis, pos- 
terior sclerosis, transverse myelitic paralysis, progressive 
muscular atrophy, etc. 

It has also long been known that nerve center changes 
take place after amputation, disuse or injury to peripheral 
nerves, etc. Toxaemia, anaemia, peripheral irritation, shock, 
etc, may derange and disease central neurones of cord or 
brain and even of ganglionic centers. 

Spinal cord changes follow operations, Switalski re* 
ports the results of an examination of five spinal cords re- 
moved from subjects upon whom amputations had been per- 
formed—four amputations of the thigh and one of the leg. 
In every case there was found atrophy of one -half of the 
spinal cord corresponding to the side of the operation, both 
the white and grey matter being implicated in the atrophy. 
In three cases the atrophy was traceable from the lumbar 
part of the cord to the dorsal region and in two 
cases up to the cervical region. Coincident with the 
atrophy there occurred a sclerosis of the posterior columns — 
in three cases in all levels of the cord, in two in the 

cervical region. While the spinal hemiatrophy showed a 
tendency to diminish from below upward, the sclerosis of 
the posterior columns increased from below upward, Pierre 
Marie also draws attention to the occurrence, not only of 
atrophy, but also of sclerosis after amputation, and states 
that such sclerosis may be noticeable, even on the opposite 
side nf the cord. — Switalski, {Rev. hleurol. Jan. 15, 1901), 
Gould's American Year Book. 

These changes illustrate Von Gudden's law of peri- 
phero-central change, while Waller's law is one of centro- 
peripheral change. 

The accompanying illustrations from Marinesco and 
Raymond show the neurone changes resulting from section 
of a peripheral nerve. 




Fig. 153. Origin t course and termination of a motor impulse. A 
pyramidal fiber, coming from a neurone. C. p, s. r in the cerebral cortex or 
central neurone, with it neuraxone, N, c. t to the anterior cornua of the 
spinal cord and pyramidal cell Cm. A motor cell prolongation neuraxone 
or motor nerve goes out at N+ p. to the muscle. 

Fig, 154. 1, anterior segment of internal capsule; 2, posterior seg- 
ment of the internal capsule; 3, genu of the internal capsule; 4, lenticular 
nucleus; 5-5, caudate nucleus; 6, optic thalamus or optic bed; 12, claus- 
tram; 13, external capsule. 





326 



CEREBRAL TRANSVERSE SECTION. 
FIG. 155. 



***** J* ^i^^rr^Sr***^ •*■ 




a, <*', bf group of pyramidal cortex neurones; a, a, cortex neurone 
sending its axone or neuraxone directly down c, the pyramidal tract into the 
cord, a cerebro-spinal fasculus or true axone of the pyramidal tract; a, an- 
other pyramidal cortex neurone sending its neuraxone the same way and 
also a bifurcation of its neuraxone across the corpus callosum to the oppo- 
site hemisphere of the brain; b, cortex neurone sending its neuraxone 
through the corpus callosum; c, pyramidal neurone with bifurcating neu- 
raxone, one arm going across to the corpus callosum opposite, the other to 
cortex of the same side; d, collateral; e, terminal callosal fibers. 

[Further illustrations of this chapter may be found in Figs. 151, 152, 

et seq.] 



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CHAPTER XXVIII. 



THE CEREBRO-SP1NAL AXIS OR NEURAX1S AND ITS NERVE CENTERS. 



GANGLIA, PLEXUSES, NEURONES AND NERVE CENTERS. IMPORTANCE OF 

THE PUPIL AND OTHER NERVE CENTERS IN DIAGNOSIS— THE 

BASAL AND OTHER GANGLIA— THE NEURAXIS 

AND THE NEURAXONE. 

The cerebro-spinal axis, also called the encephalo- spinal 
axis and designated also as the neuraxis, must not be con- 
founded with the neuraxone of a neurone, which has already 
been briefly considered. These terms might be confounded 
nominally, but the respective regions of the neuro- anatomy 
designated by them could not be confounded from observa- 
tion. The neurone, though it has itself a nucleus and nu- 
cleolus as we have already seen, is an integer of the neu- 
raxis or cerebro-spinal axis. 1 prefer the latter term, as 
most of your text- books do, for the present, because it is 
less confounding. The neurones are the nuclear nuts, so to 
speak, of the cerebro-spinal axis, out of which the neuraxis 
is developed. They are nuts for you to crack. In them is 
the meat of the nerve centers. 

The neurone is a microscopically discernable organized 
element of structure. The cerebro-spinal axis (neuraxis) is 
an aggregation of organs and centers of action, sensation, 
perception, reflection, motion, etc., made up of groups of neu» 
rones and their receiving and projecting fibers, and located 

1328] 



329 



*~ itfatfi the bony cavities of the head, neck and back. Nerve 
enters are made up of aggregated neurones, which, as we 
t ave seen, are nerve cells with all of their rnicro-anatomi- 
^1 attachments. The relation of the nut to the developed 
^xee and the tree to the forest will give you a conception, 
though not a perfect one, of the neuroses and their nuclei 
*.nd nucleoli to nerve centers and organs. The neurones, 
however, are completely developed microscopic individual- 
ly ties and make up by anatomical and physiological group - 
the several centers or neurone aggregations of the 
spinal cord and cerebrum and making with their sensory 
and motor attachments the incoming and outgoing nerve 
<onnections, the cerebellum, pons Varolii and the 
spinal cord* The upper portion of the cerebro- spinal 
or encephalo-spinal axis is made up of all the nervous mat- 
ter within the cranium above and down to the foramen 
ovale, called the encephalon, including the great brain or 
cerebrum and lesser brain or cerebellum and the interme- 
diate connecting or mid or tween brain, made up of the pons 
Varolii, the medulla oblongata, the crura-cerebri, are here lo- 
cated. The lower portion of the cerebro -spinal axis is all 
of the spinal cord and attachments located within the spinal 
canal and sacral cavity down to the coccyx. The cauda 
aquina is the lowest attachment of the cerebro -spinal axis. 
The cerebrum and cranial nerves make up the uppermost 
part and belong to this great nerve axis, while the peri- 
pheral nerves (motor and sensory) including those of the 
sympathetic system, constitute the intervening connections 
of this great nerve center line of nerve impression and ac- 
tion within the body. 

The cerebro- spinal axis or neuraxone is, as you see, an 
aggregation of important centers of nervous impression and 
expression ; centers of nerve energy or ganglionic centers. 





as they are often called in your treatises on neuro-plu 
ology. But there are other centers of nervous energy or 
force. These are aggregations or enlargements or knots of 
substance, from yayykuov, a swelling. 

There are ganglions in automatic and surgical nomen- 
clature or swellings of the muscular tendons, The latter 
are serous tendinous tumors sometimes called "weeping 
sinuses' 1 and often found on an extensor and sometimes on 
a flexor tendon of the wrist, etc. But the ganglions we are 
now dealing with is a neural ganglion or bunched aggrega- 
tion of neurones or nerves. The ganglia of the peripheral 
nervous system are those of the sympathetic nervous s 
tern and those on the roots of the posterior spinal nerve 
roots, which you will see in the accompanying illustrations 
of the cerebrospinal axis, and the ganglia of the roots or 
trunk of the cranial nerves, the most important of which 
from the standpoint of neuriatry or the treatment o\ ner- 
vous disease, is the great Gasserian ganglion or the great 
center of the three roots of the fifth or tri-facial nerve, with 
Which we become familiar in practice, in connection with the 
treatment of tri- facial or trigeminal neuralgia or prosopalgia 
or tic doloureux, as it is called. 

The geniculate ganglion of the facial or seventh nerve, 
is a peripheral ganglion which will not interest you as much 
as the Gasserian ganglion, of the fifth or tn- facial nerve, for 
the Gasserian ganglion is the one thr surgeons will want to 
take out of your tri -facial neuralgics, some of them, before you 
have a fair chance at curing them. Our surgical friends in the 
faculty, Profs. French and Keifer, wield the knife so deftly that 
they like to use it in these cases and sometimes surgery is 
the only source of relief. Some of my cases in my life time 
of practice have been passed over to the surgeon and been 
tinally relieved after many years of recurring suffering by 



331 

this formidable, but in extreme cases, when the nerve be- 
comes degenerate, very necessary operation. They were 
successfully operated on by a surgeon specially skilled in 
Gasserian gangliectomy.* Drs. Bartlett, French, MacCand- 
less, Lutz and others have also succeeded in this operation. 

The glossopharyngeal, vagus and auditory nerves have 
ganglia and the visual expansion of the optic nerve has like- 
wise. It is called the retina, and includes all of its nerve 
elements concerned in the reception, elaboration and trans- 
mission inwards of sight impression. It has been called the 
retinal ganglion or ganglion of the retina. This ganglion will 
interest you much in practice, as well as the pupil and 
movements of the iris and action of the retina, that make 
up its many interesting movements in disease, as well as 
in mental emotion. 

The ganglia of the sympathetic system comprise the 
ophthalmic (lenticular or ciliary) in the orbit, the spheno- 
palatine, Meckel's or nasal ganglia, in the spheno- maxillary 
fossa and at the other extreme the ganglia of impar on the 
anterior aspect of the coccyx. Arnold's ganglion, the otic, 
lies beneath the base of the skull, the sub-maxillary or lin- 
gual, located as its name implies, likewise the superior mid- 
dle and inferior and inferior cervical or neck ganglia, the 
middle of which is called the thyroid, from its relations to 
that gland. Then there are the thoracic ganglia along the 
thoracic spine, the semi -lunar ganglia and solar plexus back 
of and abtve the umbilicus and below the diaphragm, the 
sub-diaphragmatic ganglion under the surface of the dia- 
phragm, the ganglia of the lumbar and sacral regions ; the mes- 
enteric and renal ganglia supplying the kidneys, mesentery 
and renal and mesenteric arteries. Then there is the gan- 
glion of the coccyx, (impar), which, unlike the other spinal 

* Dr. Carson. 



332 

sympathetic ganglia, we have mention 
side of the vertebral column is placed, 
solitary and alone on the front of the coccyx. You may 
retain approximate remembrance of the location of those 
ganglia of the sympathetic system by recalling the fact 
that the ganglions of Meckel and Arnold (the nasal and 
otic) are in pairs at the upper extreme of this region and 
impar (not paired) as its name implies, is solitary and alone 
at the other and lower extremity of the trunk, while the 
other ganglia intervene and derive their respective names 
from their anatomical location and relations to viscera or 
regions of the body, except the ganglia of the cochlear 
branch of the auditory nerve, which unfortunately for your 
remembrance, is not called the auditory or aural or cochlear, 
as I would have named it for your sakes, had 1 been the 
discovering anatomist, keeping in view all the hard names 
you have to learn, but the spiral ganglion or ganglion* spiral*. 
Fortunately you will not have to keep constantly in 
mind all the names or all the ganglia of the sympathetic 
system in order to make good practitioners. You will only 
have to locate them from time to time, as you may have 
to describe particular parts on study particular viscera in 
disease. The main thing for you not to forget is that these 
ganglia are connected with involuntary visceral and vascubr 
functions, that they are in the main centers for control of 
the unconscious life-maintaining movements of the organs 
and circulation vessels. They and their neural prolonga- 
tions or nerve fiber connections have to do with uncon- 
scious motion, sensation and inhibition, They keep the 
involuntary machinery of our wondrous mechanism in 
normal movement. When disease damaged, they permit 
the marvelous machinery of man to go wrong or aid in it 
morbid movement. 




333 

The possession of involuntary sensation will be denied 
to the sympathetic system, but do not believe the conten- 
tion. There is probably more in the philosophy of the 
mechanism of the sympathetic system movements than has 
yet been described in your physiologies. Unconscious sen- 
sation in the sympathetic system is as rational as reflex 
movement and inhibition without sensation. It is here 
largely through the sympathetic system and its mechanisms 
of impression and control movement, that we live and 
move and have our being in our unconscious life, especially 
below the encephalon. There is an organic consciousness, 
if I may so express it, of which we may conceive, though 
we may not prove it; an organic consciousness to be dis- 
tinguished from psychic consciousness or the self-conscious 
consciousness, if 1 may so recall ft, which appears to reside 
in the psychic neurones of the conscious mind areas of the 
grey matter of the brain. The semilunar and solar plexus 
ganglia have been termed the ventral brain. 

CENTRAL NERVOUS SYSTEM GANGLIA. 

Notwithstanding the number and importance of the 
ganglia already mentioned, they have been called the lower 
or lesser ganglia of the nervous system. There are 
ganglia of far more primary importance called the great 
ganglia of the central nervous system or cerebro-spinal axis. 
Tlie principle of these are called the basal ganglia and 
the chief or these are the corpus striatum and the op- 
tic thalamus. These two are generally referred to as the 
basal brain ganglia, as if there were no others. The corpus 
striatum is located anteriorly a little superiorly and ex- 
ternally and the optic thalmus is placed posteriorly and in- 
teriorly and slightly internally, nearer the median line in 
relation each to the other. The hemispheres of the cere- 



brum are called the hemispheral ganglion, making the striate 
bodies and the optic beds intermediate ganglia* Below 
these are the geniculate bodies, tuber cinereum, olivary bod* 
ies, etc. The two ganglia, which all authors agree in call- 
ing the basal ganglia, that is the thalami optici and the cor- 
pora striata, I show you here in the lateral ventricles, bor- 
dering the fifth ventricle of the system, the must anterior and 
superior- The third ventricle, you see, is situated poster* 
iorally and the fourth ventricle is out of sight, but posterior 
and below the third with this canal i*'»th the long Latin 
name, in which 1 have placed the probe leading to it, the 
iter a ieriw ad quartum vetitrituium, or acqueduct of Sylvius. 
Note their situation with reference to these two important 
ventricles, the two largest ventricles of the brain, as these 
two ganglia are also the largest and most important of the 
ganglia of the cerebrum except the two hemispheres of the 
cerebrum, which are themselves called ganglia, hemispheri- 
cal ganglia. 

These two ventricles are on either side of the median 
line with their longest diameters antero* posterior, while two 
uf the other ventricles are in sight between them, the 
one, the fifth, within the pellucid septum which divides 
the lateral ventricles from each other, and the other, the 
third, on a straight line backward and emptying into the 
front end of the Sylvian acqueduct. 

The encephalo-spinal axis is originally described as con- 
sisting of the frontal, temporal and occipital lobes of the two 
hemispheres of the brain, the joined hemispheres and lobes 
of the cerebellum or little brain (the cervellet, as the French 
call it), the bridge of Varolius or pons Varolii or pons as it is 
variously called, the oblong marrow or medulla oblongata or 
simply medulla, as it is generally designated, and the co 
or spinal cord. 



335 

The accompanying illustrations ( Figs. 153 to 161 in- 
<r lusive) will explain the subject more clearly. The spinal 
c^ortl is brought into proper relation with its environment 
'V^ithin the system by means of the sensory and chiefly the 
sympathetic systems; the latter may properly be regarded as 
st system of subsidiary spinal nerves of communication with 
Inlood vessels and viscera. By means of the spinal nerves 
proper and the nerves of special sense of the brain this 
^great nervous axis is brought into contact, for sensa- 
tion and motion, with the environment of the outside 
"world and the environing body. It is the greatest aggrega- 
tion of nerve centers of the body. But as most of the 
ganglia of the nervous system, encephalic, spinal and peri- 
pheral, including also the sympathetic system, have been 
demonstrated to be centers of nervous energy, that is, to 
possess power of transtnuting sensation into various 
kinds of motion and to modify, transmit and arrest sensa- 
tion, the central nervous system can not be properly con- 
fined exclusively to the cerebro- spinal axis. Since this is 
the fact, the term neuraxis might well be restricted to the 
brain and spinal corcT, taking care, as 1 have already en- 
joined, not to confound the term with the still more re- 
strictive and microscopic term neuraxone, the efferent pro- 
longation of the neurone, as we have seen. The neuraxis 
is nevertheless the greatest part of the nervous system, the 
head and backbone nerve center arrangement of the entire 
neural framework of the human body. The many anatom- 
ical illustrations now shown, with the brief descriptions that 
follow, will illustrate more forcibly than words alone, how 
important this great cerebrospinal system really is. The 
neuraxis, like Banquo's ghost, continually comes up before 
us in the study of neurology with its psycho- neural daugh- 
ters, psychology and alienism, and will not down at our 




IV. Fourth n*rv« 

V ♦ Fifth «r»e, motor nidi. 

W.J M|ln.|iniHH»p( fifih 

V'll f 'a*.iat mrr»e. 
VICt Auditory ■*•* 

I X Gtrntfro-pbarynnii 

X V* f u* 

XI Spiml 



337 



IMPORTANT NERVE CENTERS OF THE CORD AND MEDULLA. 
FIG. 158. 



Ilypo-gtofiat X. 




mi. i» v. < 

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II v< 
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CUCh 






338 

bidding, though some of you might wish to ignore it. 
It is essential to understand the brain nerves of special 
sense and their related nerves, in origin and function, 
in order to become proficient in the diagnosis of brain and 
even some forms of spinal cord disease, especially diseases 
involving the cervical or neck region, the area of the cilio- 
spinal or pupil dilating center, in the lower part of the 
cervical cord, belonging to the brain 'region of the neuraxis 
or cerebro-spinal axis. So also are classified as cerebral 
nerves the remainder of the dozen cranial nerves, 
and they are of great importance in determining the nature 
and extent of lesions or disease. The pupil is influenced 
in its contracting striae by fibers from the sphincter pupil - 
lae or third nerve and dilation by a sympathetic nerve cen- 
ter from the cord, sending its fibers of nerve influence with- 
in the cranial cavity to the pupil. They are symptom- 
atic signboards and roads that lead and point to intracer- 
ebral centers. They tell us where to find and often the 
exact nature of the brain or upper spino-cerebral disease, 
we may be seeking to discover and understand. 

TIk j m>st important nerve extending below the f.ice and 
originating from the upper (cerebral) portion of the cerebro- 
spinal axis is the vagus or pneumo-gastric. It arises from 
the floor of the fourth ventricle and is distributed to the 
viscera of the thorax and abdomen. It might well have 
been named from its anatomical relation with the viscera 
and its origin, the cerebro-pneumo-cardio-hepatico-enteric 
nerve, so numerous and important are its relations, inser- 
tions and functions, with the thoracic and abdominal viscera. 
The next most important nerve center of the spinal 
cord, though none of them are unimportant to health and 
life, is the pudic nerve center in the lower part of the 
cord. It is the center on whose integrity depends the 



;339 

power of procreation and normal action of the genesiac 
function. 1 need not enjoin you to take good care of it and 
to neither overwork it nor to let it wrongly govern your 
life. The student who lives too much below the belt does 
not usually live best, nor does he do the most good above 
the collar. Some important diseases, mental and physical, are 
connected with genesiac center disorders. The vagus center 
and the centers there about it, in the upper cerebro-spinal 
axis, contribute to maintain or shorten life. The pudic nerve 
center, in association with the ovarian plexus, branching 
off from the renal and aortic plexuses, is closely related 
to the vesical and rectal centers in the lumbo-sacral 
region of the lower neuraxis, and aids in the propogation 
of life. The genital, rectal and bladder functions are 
extensively innervated and maintained from this region qf 
the encephalo-spinal axis. The seminal and ovarian man- 
ufactures have their life making and life continuing plant 
located near by in the pelvis and further up in the cord 
and the two great reservoirs and secretory sewers of the 
body have their cess-pools and waste product exits in the 
vicinity here, and they are presided over and regulated in 
the very important functions of holding in or expelling their 
contents, by this part of the cord. 

The term center comes from the Greek kottiw, signi- 
fying a point around which a circle may be drawn. And, 
as in geometry and mechanics, we have centers of curva- 
ture and gyration, in hydrostatics and mechanics, centers of 
pressure, and in physics centers of cohesion and attraction, 
and in astronomy centers of gravity and motion, so in neu- 
rology we have centers of impression (direct and reflected 
impression action) and expression and repression, and these 
centers are designated nerve centers, the nerve centers of 
the encephalo-spinal system, including the sympathetic and 



340 



Fig. 159 (opposite page) is the spinal incasement of the cerebro-spinal 
axis showing, after an illustration of Gowers, the relation of the vertebral 
spines to their bodies and the nerve roots. The ends of the vertebral 
spines are opposite the middle of their own bodies in the lumbar region only. 
They correspond to the lower edge of their own bodies in the cervical and 
last two dorsal, and to the upper part of the vertebral bodies in the remain- 
ing dorsal region. 

A careful study of the illustration will help you to understand the 
mutual relation of the cord segments and nerve exits as well as the spine 
and body vertebral relations. Note that generally the spinal nerves emerge 
from the vertebral interspaces at a segment below their points of origin. 

The sixth dorsal nerve has its origin opposite the fourth dorsal 
vertebra, the fifth lumbar nerve between the eleventh and twelfth dorsal and 
the sixth dorsal nerve between the third and fourth dorsal spines. 



ILLUSTRATIONS OF PARTS OF THE NEURAXIS OR CEREBROSPINAL AXIS 
AND CONNECTIONS, CHIEFLY BELOW THE ENCEWHALON. 




^ 



Fie, 161. tncep. n'O'Spinai mnd Jf»n* 
ctldted nerve* t (Herrler. after Qualn .) 



He. 159. Relations of ttiesplm 
bodies and spinous processes d | 
The posiion* of the letter* <ind numbers, 
clearly Indicate the parts. I Aflw * rowers.) 

» 1, untero- Inferior *all of the fourth ventricle: 2, til] I The cerebel- 

lum ; 3, middle pedunc'e Of the cerebellum : 4, Interior peduncle of the cerebellum ; 5. 
Interior portion nl the posterior median columns of the cord: ft, glosse- pharyngeal 
nerve; 7, pneumogastr. norve; 9,9 led ligament; 

10.10. 10. 10. postttim vpin,i/ ntn.fi; 11, 11, 11.11, pesttriof Utftmt 

groove: 12. 1 £ 12, 11 'he poitertor root interior 

if the ttervei, 14, divUion ^t the nerve* imto two brauekst; 1 .S lower extremity 
of the cord; 16. 16. .ooygeal ligament; 17, 17, cauda en ulna: I— VI II, <-. - 
I. II. Ill, IV— XII, dfWjii/ «^rw; I. II — V, lumbar arrsvs; \— V, ixct.tl xervit,— Hirstk- 
feU. i For further descrlptl j>n see nexl page.) 



342 

the vaso-motor or the vaso-motor and the vaso- constrict- """" 
systems of the nervous system concerned in contracting c^ 
dilating the blood vessels — the vaso-motor system. An — 
these are all subject to disease or disease impression an^* 
you must therefore know something about them. 

Plexus is the Latin for a braid, a plait or an inter — 
lacing. There are various interlacings and there are nerv^ 
interlacings or plexuses as well as nerve ganglia. They 
should not. be confounded with nerve ganglions. The 
former is an aggregation of neurones, the latter a mingling 
of nerves. The spermatic or pampiniform plexus is a 
venous plexus with nervous innervation from a ganglionic 
center, by which nervous innervation every properly regu- 
lated man is expected to maintain due control of his 
pampiniform plexus, though its control is not one of direct 
voluntary control, but indirectly, through restraining the 
emotions, well ordering the thoughts and properly manag- 
ing peripheral influences. Do not pander to your pudic 
nerve or pampinform plexus, or to the organs they are in 
relation with, young gentlemen. 

[Further illustrations of this chapter may be found in 
Figs. 151, 152 et seq.] 



343 



FIG. 162. 



Anterior cerebral *. 











Bourgfry's out ine lateral view anatomical diagram of the cerebro- 
spinal axis nf neiraxis tram Quain's anatomy, showing the cerebro-splnal 
cavity noii the top of the Drain with the cranium to the enJ ol the spinal 
cord, cauda e.i"f«ia and cocyx. F. T and O are the frontal, temporal and oc- 
capital lobes ol the cereorum; C, P and Mo are tie cerebellum pons Varolii 
and m?du U ""lungata; PA and Ms shiwthe upper and lower extreme 
the somai imrJ; Ce. the cauda equina at the lower end of the spine be- 
ginning with toe list luimar spinous; V, ganglion of the fifth nerve 
or the trigeminal, nr ^an^loi of Gisser with its three branches faintly 
sh?wn; C L shiv-i ths first of the spinal nerves or first cervical coming 
out uider tad occiput, a'd Cvill is the last or lowest cervical; Dl Is the 
firs' d>rsal or t h > n : i ; and DXll is the twelfth or loves' and last dorsal The 
first sacral nerve b-?<ins at Si; SV is the fifth sacral; S Is the sacral plexus 
and Col is the coccygeal nerve. 



CHAPTER XXIX. 



THE NEURAXIS AGAIN, DIAGNOST1CALLY VIEWED. 



^> CURSORY DEMONSTRATION OF CRANIAL NERVES— THE COLUMNS OF 
THE SPINAL CORD AND THE NERVES THAT GO TO AND COME 
FROM IT-THE CORD SEGMENTS OF IMPRESSION AND IN- 
FLUENCE—OUTLINE OF THE CEREBRAL AND SPINAL 
NERVES AND NERVE CENTERS AND THEIR RELA- 
TION TO NERVOUS DISEASES. 

To fasten this important matter firmly in your minds, 
We introduce again Bourgery's outline lateral view anatom- 
ical diagram of the cerebro-spinal axis or neuraxis from 
<2uain's anatomy (Fig. 163) its relations to the cerebro- 
spinal cavity, from the upper infeiior surface of the cra- 
nium to the coccyx, and an illustration of the under surface 
of the brain, the crura cerebri, pons Varolii, medulla ob- 
longata, showing apparent or external cerebral nerve exits, 
together with a brief outline of the spinal nerve origins. 

F T O are the frontal, temporal and occipital lobes 
of the cerebrum. G P and M O are respectively the 
cerebrum and pons Varolii, medulla oblongata; Ms, Ms show 
the median line above and below of the spine; Ce, shows 
the cauda equina at lower end of the spine beginning with 
the last lumbar spinous process; V, if you scan it closely, 
shows the ganglion of the fifth nerve, otherwise called the 

[345] 



346 

trigeminal ganglion or ganglion of Gasser, with its three 
branches faintly shown. Now look at the base of the brain 
and the fifth nerve here. This nerve is the seat of an 
often trying and sometimes intractable and excruciatingly 
painful trouble called prosopalgia, tic douloureux, trigemi- 
nal or tri-facial neuraglia, its diagnostic characteristic being 
a paroxysmal pain, passing along the course of the branches 
or twigs of this nerve and suddenly changing, often from 
one branch to another. 

This is the large nerve that 1 have often demonstrated 
as seeming to sprout out from either side of this beautiful 
bridge, about the middle of it, as we look across from be- 
fore backward, more beautifully curved and delicately and 
strongly constructed for its wondrous purpo>es 1I..111 any 
bridge of man's contrivance, as the poets have described it. 

The origins of these nerves are deeper down from the 
nuclei in the floor of the fourth ventricle on opposite sides, 
(from whence so many other of the cranial nerves arise), 
eight of the twelve nerves of the brain, leaving out only 
the fourth, third, second and first pairs. The nerves of the 
brain seem like the twelve apostles, to have one chief end 
in view, namely: the salvation and service of the soul of 
the human organism, that is the neurone centers of the 
brain. 

If you look a little farther beyond the pons Varolii, fol- 
lowing these two roots till we reach the pars petrosa ossa 
temporalis, as they say over in Berlin, but as we say in 
English, as far as the petrous or especially hard portion of 
the temporal bone, we find a lump or enlargement or 
ganglion developed in the sensory root, after the manner of 
the ganglions on posterior sensory roots of the spinal 
nerves. This expansion or ganglion may be likened to 
the stubby trunk of a palm tree with three principal 



347 

branches, one the ophthalmic nerve going to the eye and its 
vicinity (lachrymal, palatin, nasal) branches with numerous 
sub-divisions, another going to the teeth and mucous mem- 
branes of the* upper jaw and face, the superior maxillary, 
and the third, the inferior maxillary, going to the cheeks, 
teeth, temple and tongue and many facial muscles. 

We will not present in minute detail all of the distri- 
butions of this nerve. It is in one of its branches only a 
compound or motor and sensory nerve. The combined 
sensory and motor branch is the inferior maxillary nerve. 
The ophthalmic and upper maxillary branches are only sen- 
sory. You will need to keep handy for purposes of diag- 
nosis, accurate anatomical tables like those in some of your 
text-books or in Flower's diagrams. If you do not you will 
get the origins, distributions and functions of the fifth and 
seventh nerves mixed. This might result disastrously, es- 
pecially in the practice of surgeiy, as it did once in the 
practice of that eminent surgeon, Sir Charles Bell, giving 
the profession as a result a more intimate knowledge of 
that distorting form of seventh nerve or facial paralysis, 
called after the great surgeon's mistake in cutting the fa- 
cial for the tri-facial in a case of tic douloureux, Bell's palsy 
or Bell's paralysis, that form of palsy resulting. 

A man's blunder sometimes makes him famous as 
well as his successes and we always think of Sir Charles 
when we see a poor devil who used to whistle, but who can 
no longer pucker his mouth (for that ordinarily distress- 
ful performance to unwilling auditors), and one of whose eyes 
stands wide open when he would close them both at your 
request, if he could, and whose mouth draws to the oppo- 
site side of the victim's face when he tries to speak. We 
know Sir Charles Bell by the facial palsy he unwittingly 
demonstrated, better than we know him by the respiratory 



348 

nerves that bear his name, and quite as well as we know 
him ^as the discoverer of the motor and sensory nerves as 
separate nerves of the cord. The.tri-facial nerve is a fa- 
cial nerve as you also see, as well as the seventh nerve. It 
supplies the skin of the face chiefly. It supplies the cornea, 
mucous membrane of mouth and nose and dura mater, with 
fibers of sensation. Its branches supply the skin of the 
cheeks, lips, chin and temples and anterior part of the sur- 
face of the tongue. As a motor nerve it has more to do 
with the movement of the lower half of the face than its 
prototype, the facial or seventh nerve. The fifth nerve motor 
branches move the muscles of mastication, the masseters, 
the temporals, the pterygoid, the stylohyoid and the anterior 
belly of the digastric muscles. The tri-facial nerve or 
fifth nerve is more of a sensory nerve than a motor. The 
facial or seventh nerve is more of a nerve of motion, for 
the expressions of the face especially. It has been called 
the mimic nerve of the face. 

The fifth nerve has ganglionic relations other than with 
the Gasserian ganglion, viz: The ophthalmic, lenticular or 
ciliary ganglion, Meckel's or the spheno-palatin ganglion, the 
otic and the sub-maxillary. All connection with the fifth 
nerve is by the sensory root, an important thing to remem- 
ber, for when sensation dies in the root, connection is nil. 
The otic, Meckel and submaxillary ganglions have motor 
connection with the seventh or facial nerve and the ciliary 
or ophthalmic with the third nerve, while filaments from a 
vaso- motor sympathetic plexus go to all of these ganglia. 
We feel most with the fifth nerve about the face, and sen- 
sory uervous diseases belong, like toothache and neuralgia, 
especially to it. We express most with the seventh. It 
is a nerve of facial mimicry, pantomime and facial expres- 
sion. It is the chief seat of facial paralysis, palsies and 



349 

"tics, facial tremors, through close sympathetic relations with 
*he fifth. 

The fifth nerve is a wonderful nerve, the seventh is 
likewise. Here is the seventh clear across the Varolian 
bridge, coming out from the lower under surface of the 
bridge, from between the restiform and olivary bodies. So 
also are the sixth or motor oculi externus or abducens 
nerves next to it. When they are paralyzed the eyeball 
can not be turned outward. They come from under the 
bridge, too, between the bridge and the tops of the pyramid 
on either side of the median line. Here is the fifth com- 
ing from the middle of the side of the bridge almost in a 
direct line, antero-posteriorly with the fourth or pathetic 
nerve which comes out from under the bridge, too, but su- 
periorly where the outer line of the crus cerebri or brain 
leg passes downward with its many fibers of motion and 
sensation under the bridge to the cord and other connec- 
tions. It comes from under the bridge, not from the fourth 
ventricle where eight of its neural companions originate, but 
from the way there, from the acqueduct of Fallopius, not 
like the Appian way from Rome to Brundesium, paved with 
stones by a great Caesar's command, but paved by a greater 
than any Roman Emperor, and with precious neurones, which 
are the centers of life and neural power, the way from the 
third to the fourth ventricle, iter a tertio ad quartum ven- 
triculum. This passage way between the third and fourth 
ventricles gives origin to the fourth cranial nerve. 

But yet another cranial nerve, the third or motor 
communis, arises deep-seated from the floor of the Sylvian 
way or acqueduct of Sylvius and here it is, nestled here be- 
tween the crura of the brain, where they appear to join in 
the median line anterior to the pons to pass under the 
bridge and go down the spinal cord. And a wonderful 



350 

nerve too is this common motor oculi. It has wonderful 
eye motor connections and receives fibers from the cavern- 
ous plexus of the sympathetic. 

1 We have seen already that it has connection witli the 
ciliary ganglion and it is through this relation that it reaches 
the ciliary muscle and has power to contract the pupil. It 
is the sphincter pupillae muscle nerve of your anatomies. 
It connects with and innervates all the rotary muscles of 
the eye except the superior oblique and external rectus. 

Wonderful nerves are these eye-moving nerves. They 
move the hearts of man and woman figuratively, not ana- 
tomically speaking, except only reflexly from the brain and 
mind and they move the world, not with an Archimedian 
lever, but by means of men and minds influenced through 
their movements. But we shall recur to these nerves and 
other of the cerebral nerves again and again. They and 
the others of the twelve, have much to do with our ability 
to diagnosticate what is going on in the brain when disease 
attacks this important, commanding, superior part of the 
neuraxis. 

Let us go forward before we leave the subject to the 
two brain nerves that have no connection with either the 
third or fourth ventricle or the iter, viz: the first and the 
second. Here is the nerve of smell which we test with 
odors for anosmia, hyperosmia and other defects of smell in 
trying to make our diagnosis. These are often damaged in 
function when the anterior median under surface of the brain 
is diseased. Its origins are here in the anterior and middle 
lobes and in this perforated space. The fifth nerve, as we 
have seen, has two roots and three branches, but this has 
three roots and branches down into the nasal cavity walls 
like the hairs of a dusting brush. Here is the optic or sight 
nerve, with its crossing fibers making the crossing, or de- 




351 

cussation, as it is called in the chiasm. It also has non -decus- 
sating or non-crossing or lateral fibers, going back to find final 
connection with the occipital lobes, but connecting on their 
-way with the corpora quad ri gemma and optic thalamus here. 
Here is the eighth or auditory nerve, one of the eight 
cranial nerves coming from the fourth ventricle. It goes to 
the internal ea . It joins the facial in giving off a filament, 
which, blended with that of the facial, makes up the nerve 
of Wrisburg, the chief source and origin of the chorda tym- 
pani. Here is the ninth or glossopharyngeal coming from 
the fourth ventricle and going to the posterior third of the 
tongue, the seventh nerves here supply the anterior two- 
thirds of the organ.* Here is the vagus, that vagrant nerve 
which wanders to the larynx, oesophagus, lungs, heart, stom- 
intestines, liver, kidneys and supra renal capsules and 
spleen and is often in evidence clinically and diagnostically, 
as when it is irritated, the heart is abnormally slow or par- 
alyzed. And it is the heart movements and the respiration 
that are, in consequence, abnormally fast or cease altogether. 
Here are the accessories supplying the sterno-mastoidii and 
trapezii, as evidenced in wry neck or scapular palsy or 
spasm, and the hypoglossus that moves the tongue drawing 
it toward the paralyzed side when it is paralyzed. It inner- 
vates for motion the genio-glossus, hyoglossus, genio-hyoid, 
omohyoid, hyothyroid, sternothyroid muscles. It has a good 
deal to do with keeping up appearances about the tongue 
and throat. Vide Figs. 162 ei sequitur, 

•These two tongue nerve*, when diseased at thdr distribution*, or along their course, 
five abnormal sensation* of taste or pyraguesias. When destroyed in their course, distri- 
butions or at their origins, taste Is destroyed. Ttits condition Is technically termed aguesta. 
HemiMngual aguesla sometime* result* from central bulbar causes like hemleiossnplejrij. 
Hemlaguesla sometime! results, like hemtanaesthesla. from hysteria. It may result from a 
unilateral organic brain disease Involving the bulbar origins of either the ninth or seventh 
nerve* or from disease of the cortical center for the sense of taste In the temp ero- sphenoid * l 
lobe area Aguesia of the anterior two-thirds of the tongue point* to facial nerve per- 
ipheral or central morbid Implication ; off the posterior third of the tongue to glossopharyn- 
geal, or ninth nerve, course or cenier Involvement. When the glossopharyngeal aguesla 
appears, the soft palate and pillars of the fauces become synchronously Involved, if the 
cause of the trouble Is central. As aguesia without peripheral lesion of either the seventh r>r 
ninth nerve points to central disease and paraguesla to mouth and stomach perversion, so 
psychical paraguesla may be a symptom of hysteria or Insanity ; the perversion of taste 

mosmla being in the psychic centers and due to cerebral disease. 



CHAPTER XXX. 

OUTLINE OF THE CEREBRAL AND SPINAL NERVES AND NERVE CENTERS 
AND THEIR RELATION TO NERVOUS DISEASES, ETC.. CONTINUED. 



Laying'aside this brain and resuming our description of 
this antero- posterior longitudinal hemi-section of the cer- 
ebrospinal axis we have here (Fig. 163) at OI, the first 
of the spinal nerves or first cervical coming out here under 
the occiput and VIII is the last or lowest cervical. Bl is 
the first dorsal or thoracic and DX1I is the lowest and last 
dorsal. Thel-first sacral nerve begins here at SI; Sv is the 
fifth; S is the sacral plexus and COI is the coccygeal nerve. 

The surrounding parts, as you see, belong to the bony 
encasement of this great nerve center bony canal, made up 
of the cervical, dorsal and lumbar vertebrae with their bod- 
ies in front, spinous processes behind and continuous 
canals in close and marvelous relation for the protection, 
holding and transmission of the spinal cord between; the 
basin-shaped pelvis, being, as its name implies, the basin 
floor of this great nerve center column, the cranial vault 
resting like a dome or cupola on top. 

The spinal cord is the flattish cylindroidal continuation 
of the medulla oblongata into the vertebral canal, enclosed 
in the theca vertebralis or vertebral sheath and ex- 
tending to the level of the lower border of the first 
lumbar vertebra; here it suddenly narrows to a terminal 

[352] 



353 

cone (conus terminalis) which tapers to a slender glisten- 
ing terminal strand (filum terminate) , in the center of the 
cauda equina, traceable as far as the third sacral vertebra. 
From each side of the spinal cord arise the thirty-one pairs 
of spinal nerves, which leave the vertebral canal through 
the inter-vertebral foramina.* 

The female cord more often than the male reaches to 
the second lumbar vertebra. That woman (with a smaller 
brain) should have a longer cord than man may be due to the 
extra pelvic demands upon her cord centers. 

The levels of escape from the cord of the various 
spinal nerves vary, as we may see by Go wers' table. 

The cord contracts at the medulla oblon gata, widens 
from the second cervical to the first dorsal vertebra, again 
contracts from this point to the eleventh dorsal, where it 
again dilates, to narrow again at the top of the first lumbar 
vertebra. The upper is the cervical enlargement, the lower 
the lumbar enlargement. Its general form is cylindrical. 

"The spinal nerves are connected to the spinal cord 
by two roots (Fig. 139) one of which, the efferent or motor, 
(5), arises from the anterior aspect of the cord; the other, 
the afferent or sensory (6, Fig. 139) is connected with the 
posterior surface. After a short, independent course and 
the development of a ganglion (6, Fig. 139) which is, there- 
fore, a mixed nerve, containing both afferent and efferent 
nerves. The nerves distribute themselves by minute rami- 
fications to the receptive organs and the periphery, each 
filament remaining distinct in its own course. 

♦The average dimensions of the cord are as follows: 

Male length, 43 cm.* Volume 34 ccm.; weight, 34 grammes. 
Female " 40 " " 30 " " 29 

Motion of the vertebral column does not appreciably affect the level of the end of 
the cord. The foetal cord extended originally the whole length of the spinal canal, 
but the vertebral column begins to outgrow It at the tenth week, and by the time of birth 
the cord only reaches as far as the second lumbar vertebra. The outgoing nerves which 
at first passed horizontally outward to their respective metameres, become more and more 
oblique and retracted within the theca. owing to the inequality of growth. 



354 

The spinal cord itself consists of central gray matter 
and white columns or strands. The gray matter has the 
form of a double crescent with the convex surfaces joined 
by commissures, in the center of which the central canal of 
the spinal cord is seen (9), and the horns of the crescents 
are connected respectively with the anterior and posterior 
roots of the spinal nerves. 

The cells of the anterior cornn are large and multi- 
polar, those of the posterior small, and mingled with 
what is termed gelatinous substance. The conducting 
strands form the great divisions or columns, the anterior, 
the lateral and posterior. (See description of Figs. 139, 
146, 147 and 148.) 

The efferent or motor impulses pass down and from 
the cord along the motor nerves, chiefly on the sides from 
which the roots emerge. Hence a tumor pressure disease 
on one side of the cord or hemi- section, causes paralysis of 
motion chiefly on the same side of the body, in the parts 
below the section. 

The sensory or afferent impressions are received by the 
cord and conveyed up to the brain chiefly in the opposite 
half of the cord to that into which the sensory root sinks. 
Hemi -section of the spinal cord causes loss of sensation on 
the opposite side of the body in all parts below the sec- 
tion; increase of sensibility and paralysis on the same side 
as the lesion. 

The antero- lateral columns of the cord are the chief 
motor paths. A certain injury or disease of one side of the 
spinal cord not involving the brain, causes that form of par- 
alysis of motion on one side and sensation on the other 
side known as Brown- Sequard's paralysis, illustrated in this 
diagram. (See Brissaud's diagram.) 

The cerebro-spinal axis, at the top of which is the 




355 

brain, is brought into harmonious touch in health and into 
inharmonious touch in disease with its environment, within 
as well as without the body, by means of the twelve cra- 
nial and thirty-one pairs of spinal nerves whose origins are 
shown in the illustrations under the head of neuraxis or 
cerebro- spinal axis. 

These nerves, as we have seen, are afferent and sen- 
sory, *'. e. 9 conveying impressions to the cerebro-spinal axis, 
(which includes the brain), and efferent or motor, carrying 
impressions or expressions outward. 

This nervous arrangement makes up the sensory and 
motor nervous systems, as it is combinedly called. The 
sensory nerves of this system, carrying impulses directly to 
he brain, by means of the twelve pairs of cranial nerves 
and directly to the spinal cord and indirectly up to the brain 
areas of the neuraxis, may be likened to the dendrites and 
neuraxones of the nervous syslem, as we have said; the 
cellulipetal influence going to the cell or neurone center or 
cord center and the cellulifugal nerve influence conducting 
paths, carrying impressions away from the spinal cord seg- 
ment or the neurone center. The terms sensory and mo- 
tor embrace all the action probably belonging to these two 
means of communication of nerves center with periphery, 
viz.: feeling or motion, or sensation and impression. Sensory 
impressions from the place of peripheral destination and 
motor stimuli from the point of origin of these nerve con- 
connections and relations, make up the whole of their 
function, beside the work which is done in the neurones 
themselves that constitute in aggregate the nerve centers. 

The work of the central neurones is to receive and send 
on unchanged, or to change into motor impulse and send out 
or to elaborate and otherwise transform peripheral impres- 
sions, as in the reflexes of the spine and medulla or of the 



356 

eye, nose or ear, or to inhibit or arrest impressions, as in 
the vagus center, over the movements of the heart and the 
higher but similar movements of reflection and deliberation 
in the exalted mind centers of the gray cortex of the brain, 
that grand grouping of psychic neurones which makes the 
brain of man the temple of thought and the palace of the 
soul. 



FIG. 165. 



?Wvf£ 



wiJ^-Sft* 



»^cL>v. 




Fibers of the direct pyramidal tract conduct inhibitory influences to 
the motor neurones of the anterior horns. When they are damaged In paral- 
ysis, spastic or spasmodic states appear, going out from the cord. 



Because of the fact that after destruction of considerable 
areas of the lateral columns, neither motion nor sensation is 
absolutely paralyzed in any particular part, it has been 
maintained for the spinal cord, as it has been for the brain, 
that a vicarious interchange of function exists between dif- 
ferent parts of the cord. And there is some truth in this, 
but the variation is not sufficient to invalidate the general 
law. Above the foramen magnum the spinal cord becomes 
the medulla oblongata, which we will discuss as a part of 



357 

the neuraxis in connection with the brain, it being usually 
described by anatomists as a part thereof. The brain or 
encephalon, includes all the cerfebral mass within the cra- 
nial walls and above the foramen magnum cranii. 

The gray matter of the spinal cord is, as you see, cen- 
tral or internal in relation to the white. The reverse exists 
in the brain, the gray matter being external. The nerves 
of the brain and cord are white; conducting nerve tissue 
is generally white. Nerve matter in gross, that which re- 
ceives, originates, generates, elaborates, arrests or decides 
nerve function, is generally gray, so far as we know. The 
white matter waits upon the gray and carries its messages 
of sensation or impression to the gray centers and receives 
from them its commands. 

The upper and mid-dorsal regions of the cord are the 
favorite seats of Brown-Sequard paralysis. The leg will be 
motorially useless on the side of the injury, with increased 
patellar reflex, (sometimes lost reflex on the same side), cu- 
taneous hyperesthesia, hyperalgesia; loss of muscular sense 
with anaesthesia and analgesia on the opposite side and the 
muscular sense on the side of injury intact. 

If the source of this paralysis is in the cervical region, 
it causes hemiplegia, that is, paralysis of the leg and arm 
on the same side and anaesthesia of the opposite leg and 
trunk. In a one-sided lesion of the cord, in the sacral re- 
gion of the cord very low down, sacral paralysis of sensa- 
tion and motion are on the side of the lesion, because very 
few sensory fibers belong to the other side, as this illustra- 
tion of Brissaud shows. (Fig. 166.) 

Paralytic disease located high up in the brain on one 
side causes opposite loss of motion with or without loss of 
sensation on the opposite side, according to its extent or lo- 
cation. Suspect paralysis of brain origin when you have a 



35a 

sudden loss of consciousness and loss of power of motion 
on the opposite side of the body, persisting after return of 
consciousness. Suspect Brown-Sequard paralysis when be- 
low the neck you have loss of motion on one side and loss 
of sensation on the other, without history of sudden loss of 
consciousness. 



FIG. 166. 







359 
THE RAILWAY NEURAX1S. 

This psycho-neurosis may result from the shock of rail- 
way accidents, or from the repeated shocks to the head and 
cord neurones, received by railway employes long in rail- 
way service, short of those extreme degrees of injury caused 
by fractured cranial bones or dislocated vertebrae. The 
over mental strain of too long hours of an excessively 
exacting and vigilant service, gives the neurones too little 
rest and sleep for perfect recuperation in many departments 
of modern railway work. Too constant psychic neurone 
service is exacted of the brain, and after a time the 
central capital of reserve force is exhausted and collapse 
comes from causes which, in the beginning, would not 
break the brain. 

The principal symptoms are an impaired nerve tone, 
apepsia nervosa, intestinal atony, insomnia and sensory 
disturbances, cerebral and medullary hyperesthesia, peri- 
pheral anaesthesia and other impaired sensory perceptions, 
facial tics and spasms, memory failure and the mental de- 
bility and timidity of neurasthenia. The power of extract- 
ing nutrition from the blocd to adequately sustain the 
normal mental spontaneity and neurone vigor of action has 
become impaired. Metabolism is changed by shock and 
the apathy, irresolution and morbid apprehensions of neura- 
trophia and neurasthenia have settled upon the psychic 
neurones. The condition appears to be one of cerebro- 
spinal shock and consequent retrograde change and cere- 
bral and spinal neurasthenia, in which the nutrition and 
tone of the neurones of the neuraxis is changed. 

The modern rapid transit, jerkily moving and often too 
suddenly stopped street car,and sky-scraper building elevator, 
may cause the same condition of the brain and spinal cord. 



360 

NERVOUS INFLUENCE IN CAUSING HEMORRHAGE 
AND NEURAX1S HEAT. 

Traumatisms and grave shocks of the spinal cord and 
brain may cause increase of temperature, but so ordinarily 
does any great violence to the cerebro-spinal axis or to the 
viscera connected with the neuraxis. Excitation of the 
motor area for the leg and thigh of one cerebral hemisphere 
has caused increase of temperature in the limb supplied by 
the descending decussating fibers to the opposite limb, but 
the rabbit and dog experiments by brain excitation usually 
give rise to general elevation of temperature. It is not 
strange, therefore, that various sections of the brain base 
should cause rise of temperature. Schreiber's section of 
the medulla where it joins the cord causing increased brain 
heat in the pons, is not, therefore, remarkable. 

H. C. Wood, an eminent American neurologist, conjec- 
tured the existence of heat centers in the brain many 
years ago. Isaac Ott, whom I have already mentioned, 
in 1884 located heat centers definitely in the corpora 
striata of rabbits; in the following year he found heat cen- 
ters in the optic thalami. Sachs and Aronsohn have 
confirmed Ott's experimental conclusions, while Richet, a 
Frenchman, found a heat center in the anterior part of the 
brain and Tscheschichm, a Russian, found one above the 
pons. These, as well as Budge, Tussana and Christiana, 
according to the studies of my lamented friend, Landon 
Carter Gray, have found the brain to be a source of heat 
elevation under traumatism. (Vide article Heat Centers, L 
C. Gray's Nervous and Mental Diseases.) 

Hemorrhages have been found in the viscera, lungs, 
stomach, kidneys, etc., after injuries to the basal ganglia, 



361 

crura cerebri and medulla, and after violent concussion 
without injury. 

The experiments quoted show that heat is generated by 
nervous influence. Through these thermogenic centers we 
have a neural as well as chemical heat phenomenon in 
animal organism . Neither what 1 may tell you nor what 
your books of to day tell you, will give you all you are yet 
to learn in life concerning neural and extra-neural symp- 
tomatology and semiology connected with nervous diseases. 
Some of you are probably destined to make a name and 
fame for yourselves by further discovery in this direction. 
I wish that the names of all of you may become enrolled 
high on the keystone of fame's triumphal arch for good 
work done in this direction. 

Some railway surgeons, who are often better operators 
than neurologists, an J more accustomed to seeing and treating 
those sensible injuries patent to the natural eye, where a 
fractureJ or dislocated bone or other markedly apparent 
wound in the anatomy calls for their aid, often display a 
real or affected skepticism as to the possibility of the neu- 
raxis being hurt in its n± urone center groups, without an 
appreciable hole or other mark of great violence in the 
anatomy, to account to th em for the nervous disturbance. 
They are doubting Thomases who must first see the im- 
print of the nail before believing in the possibility of the 
symptoms; yet true surgery with all great surgeons who ob- 
serve and think beyond the mere technique of their art, 
ecognizes concussional and violent straining of the higher 
nerve centers, even extreme psychic or fright shock, as 
capable of suspending and damaging central nerve function 
without sensible external injury. The ready explanation of 
the smaller-calibered surgeons, for what they can not readily 
understand among the traumatic neuroses, without a dis- 



362 

located or fractured back or cracked skull or profound ec- 
chymosis, especially if the unfortunate victim be a woman, 
is hysteria. They forget, or ignore, or mayhap have not 
yet conceded the existence, of those groups of neurones in 
the gray substance of the cord which constitute centers of 
trophic influence which affect the motor, sensory, conduct- 
ing and inhibitory functions of the cord. But 1 cannot here 
pursue the subject further. You must, at your leisure, 
consult such books as Erichsen on the one side and Page 
on the other. Page has made the most of the hysterical 
view, and hysteria, in those who have the latent hysterical 
diathesis, is often brought out into full action when it other- 
wise might have been dormant for life, but for some grave 
accident or powerfully depressing, neurone depraving, and 
instability exciting, psychical impression. But in such a 
case the hysteria itself is the result of the exciting cause, 
and if this cause be a violent accident, we may justly call 
it traumatic hysteria, if without the traumatism it would 
likely have remained dormant. If the hysteria pre-existed 
in the woman it could not justly be called traumatic hysteria. 

The sensori- motor tract of the cerebro-spinal axis is con- 
nected with the various motor displays of prehension, limb, 
finger, toe, tongue and eye sensation, and with all of the 
reflexes, spasm and other forms of contracture, normal or 
abnormal, such as those of morbus Thomsenii, post-hemi- 
plegic paralysis, chorea, hysteria, convulsions, etc. The 
tremulous movements of extreme nervous fatigue, of paralysis 
agitans, of disseminated sclerosis, tic douleureux or tri-facial 
neuralgia, the jerky movements of chorea, the rhythmical 
movement and unfixed digital attitudes of athetosis, etc. 

The sensory nervous system reveals the nerve chan- 
nel paroxysmally darting pains of sciatic and other neural- 
gias, and the lightning pains and cincture feeling of loco- 



I 



363 

motor ataxia. It reveals to us the anaesthesias, the hyper- 
esthesias, the analgesias, hyperalgesias and parasthesias 
in various forms of sensory illusion or hallucination and the 
normal and abnormal distance points, as shown in healthy 
or diseased states of the peripheral or sensory nervous sys- 
tem by aesthesiometric measurement. The cutaneously dis- 
tributed sensory nerves reyeal different appreciations of dis- 
tant points in a straight line at different parts of the skin 
surface, as we showed you when we presented that instru- 
ment of precision in sensory diagnosis, the aesthesiometer. 

DR. E. H. WEBER'S ESTHESIOMETR1C DISTANCE POINT'S TABLE. 

This table has long been the chief esthesiometric guide 
and resource of practicing neurologists for the past four 
decades. It was first incorporated in a neurological work 
in this country by that eminent pioneer neurologist, now 
deceased, Dr. Wm. A. Hammond, in his treatise on the 
Diseases of the Nervous System. 

[From MulUr's Physiology.] 

Point of the tongue }i a line. 

Palmar surface of the third finger ] " 

Red surface of the lips 2 lines. 

Palmar surface of second finger _ .. 2 " 

Dorsal surface of third finger 3 " 

Tip of the nose 3 " 

The palm over the heads of the metacarpal bones 3 " 

Dorsum of tongue, one Inch from the tip 4 '• 

Part of the lips covered by the skin 4 " 

Border of the tongue, one inch from the tip 4 " 

Metacarpal bone of the thumb . ... 4 '•• 

Extremity of the great toe.. 5 " 

Dorsal surface of the second finger 5 " 

Palm of the hand 5 " 

Skin of the cheek 5 

External surface of the eyelids 5 " 

Mucous membrane of the hard palate 6 " 

Skin over the anterior surface of the zygoma 7 " 



364 

Plantar surface of the metatarsal extremity of great toe 7 lines. 

Dorsal surface of the first finger 7 

On the dorsum of the hand over the heads of the met- 
acarpal bones 8 

Mucous membrane of the gums 9 

Skin over the posterior part of the zygoma 10 

Lower part of the forehead 10 

Lower part of the occiput 12 

Back of the hand 14 

Neck under the lower jaw : 15 

Vertex 15 

Skin over the patella 16 

sacrum 18 

" acromion 18 

The leg, near the knee and foot 18 

Dorsum of the foot, near the toes 18 

The skin over the sternum «. 20 

11 " five upper vertebra 24 

" •' spine near the occiput 24 

41 in the lumbar region 24 

11 middle of the neck_ 30 

11 over the middle of the back 30 

The middle of the arm 30 

41 thigh 30 

For convenience of reference in aesthesiometric measure- 
ments this table, made by Dr. E. H. Weber, will be 
especially necessary in .using Sieveking's, Seguin's, Ham- 
mond's or any other sesthesiometer except my own, and 
may serve you even in the use of mine. 

You will find in the museums and text-books and in the 
excellent casts of Dr. Wm. Fuller and in the descriptive 
illustrations of Ford Robertson, Bevan Lewis and Morrison and 
Barker, which I have so often shown you in my demonstra- 
tions on the brain and cord, many elucidatory illustrations 
to help you to a clean, clear comprehension of the subjects 
necessary for you to understand. Each text-book on neu- 
ology possesses some special peculiarity of description or 
illustration. Here are some further illustrations germane to 
our present sabject in addition to those already shown. 



365 



FIG. 167. 




J?**4 



Surface or central irritations of a spinal center, as of the cervical 
plexus or spinal accessory, may cause supeificially reflected or centrally 
transmitted spasms of sirgle muscles, giving the phenomenon of wry neck 
similar to the illustration (Fig. 167), which, however, Is not the typical 
wryneck, that being caused by irritation of the external branch of the spinal 
accessory, while the figure shows contraction of the splenius capitis coming 
from involvement of the cervical plexus. 

The brachial plexus, when Irritated by disease or injury, may show 
Duchenne's scapula, caused by rhcmboid, levator scapulae and serratus 
magnus spasm, drawing the inferior angle of the scapula downward. 

Many forms of spasm may be specially studied in Ross, Gowers and 
others, and the finger and hand and general retractions of hysteria may be 
studied at your leisure in the classical and detailed history of hysteria by 
Charcot, Richer, Fere, Bourneville and others, if I do not reach the sub- 
ject In a special lecture on nervous contractures before the session shall 
have ended. 



MOTOR AND SENSORY AREAS AND TRACTS OF THE INTERNAL CAP 1 


FIG, 169. 




\^^*^*^ u/$*P* \i 1 


>CVE* OPfN 




'OcriS TUftN 


Jq /^i /x ^ \/C> 


^MOUTN OMH* 






ml \ , \ /kV 


^-HlADiltrtSTyH* 


\ \ 




n^ \\ ^Sty^k^' 


^HlAD TU*N3 


j i 




r^^^ 


^-^ TON tUC 
-"MOUTH Htftj 


1 




\\ f N / ,2_^T " 


— ••NNlttf 


I \^ 






ELBOW 

^* whist 


V : ' 




^nMGta*, 


fill ■ ~T\- 


^WV /^//^feSjs^ 


***^THUMB 


■ ^^^J^rV^L' ^S^sf\T^ 


!>*fau*ik 


* ' - - r "*>™// / ^o5^Sv v, 


^H1f» 


I S^,^ A^' T Jew 


^AHKLC 


pt^/Nk l\_^/^J >^ 


^*Ntt 


■ "^^^^v^ * ^^S**" - ^ 


s>HALi.i« 


/ ^**^^^ ^*7 rf*"*N ^^\\ 


x ro« 


m 0^ >*^fc£ J J' l f^Njll 




IC, IC P Internal Capsute. 


• 


C N 5 Caudate nucleus. 




L N, Lenticular nucleus. 




N C, Nucleus caudatus. 




O T, Optic thalamus. 




S, Line of sensory area Internal capsule. 













368 




the Facial nerve and its connections, within the aqueduct 

OF FALLOPIt 
FIG. 170. 




1, Fifth nerve, with the Gasserian ganglion. 2, Ophthalmic division 
of the fifth nerve. 3, Superior maxillary division of the fifth nerve. 4 t 
Lingual nerve. 5, Spenopalatine ganglion. 6, Otic ganglion. 7, Submax- 
illary ganglion. 8, Facial nerve in the aqueduct of Falloplus. 9, Great 
superficial petrosal neive. 10, Small superficial petrosal nerve. 11, Stape- 
dius branch of facial nerve. 12, Branch of communication with pneumogas- 
trlc nerve. 13, Branch of communication with glossopharyngeal nerve. 
14. Chorda tympani. {Dal ton's Phvsiotogv.) 







1, Facial nerve. 2, Glossopharyngeal. S* Pneumogastric* 4, Spi- 
nal accessory, 5, Hypoglossal, 6. External (muscular) branch of the 
spinal accessory. 7. Superior laryngeal branch ol the pneumogastric. 
8, Pharyngeal plexus. Laryngeal plexus and upper cardiac branches of 
the pneumogastric. 10, Tympanic plexus, Irani a branch of the glosso* 
pharyngeal. (Hirschfiild, From Da I ton.) 



CHAPTER XXXI. 

THE VIRILE OR GENESIAC REFLEX AND ITS SYMPTOMATIC VALUE 
IN PRACTICE. 



The pudic nerve branches from the lower portion of the 
sacral plexus, comes out of the pelvis through the great 
sacro-ischiatic foramen with the pudic artery, gluteal and 
sciatic vessels and nerves. It then re-enters the pelvis 
and gives off the inferior hemorrhoidal nerve and passes 
along the outer aspect of the ischio-rectal fossa to divide 
into the perineal and dorsalis penis nerve. The inferior 
hemorrhoidal nerve sometimes comes directly from the sa- 
cral plexus and is not then a branch of the pudic. It is 
distributed to the rectal sphincter muscles and inferior pu- 
dendal nerves. The largest branch of the pudic nerve, the 
perineal, dividing it into superficial cutaneous and deeper 
muscle branches, sends some filaments to the sphincter and 
levator ani muscles, but it goes chiefly to the perineal in- 
tegument, the scrotum, penis, labia and anus, communicating 
with the hemorrhoidal, as already indicated. 

The muscular branches come usually from the pudic, 
pass forward and inward beneath the transverse perinei 
muscle, its terminal filaments going off to the transverse 
perinei, erector penis, accelerator urina? and sometimes to 
the bulb of the urethra. The dorsalis penis nerve is a ter- 
minal filament of the pudic, going between layers of perineal 

[370] 



371 

fascia, through the suspensory ligament of the penis and 
along its dorsum to its glans, branching to the corpus cav- 
ernosum and integument of the dorsalis penis. Its course 
is similar in the female. Ranney and Holden, from whom 
this anatomical description is mainly abbreviated, here in- 
troduce a note from Hilton to the effect that the integu- 
ment of the side of the penis is supplied by the perineal 
branch of the inferior gluteal nerve and from no other 
source. This probably explains why the virile reflex is so 
much more rapidly obtained by dorsal than by lateral tap- 
ping of the organ and by the upward jerk or slow tension 
of the foreskin. 

The pudic nerve is a nerve of sensation and motion of 
the genitals and genital regions of the body, the perineum 
and integuments, the urethra and clitoris, their mucous 
walls and linings, the penis and scrotum. It is a sensori- 
motor nerve of special, as well as pain sense, the nerve of 
the genesiac sense, in main part at least, notwithstanding 
the probable associate genesiac function of the inferior 
gluteal, inferior pudendal and some cutaneous filaments of 
the small sciatic* 1 believe the pudic is the nerve sui 
generis of the virile or genesiac reflex, especially in its in- 
fra-umbilical areas. The pudic nerve and its close perineal 
relations with the lesser sciatic and some of its branches 
in its distribution and peripheral reflex sensibilities and re- 
lations, defines the boundaries of the virile or genesiac re- 
flex areas. The virile or genesiac reflex phenomenon is a 
pudic nerve area reflex. It is the diagnostic reflex of the 
sexual spinal cord sphere in the normally sexual individ- 

*lt elves motion t« the muscles of the perineum and urtJfcra, sensation to the Integu- 
ment of the perineum, scrotum, labium, penis and the mucous covering ot the clitoris and 
the lining of the urethral canal. The friction made upon the cutaneous nerves of the ex- 
ternal genitals creates a reflex act from periphery to cord, and psychic impression from 
brain to genlto-urlnarv centers, causes genital congestions, genital and perineal contraction, 
which expel the seminal and Bartoline secretions, urine, etc., etc. 



B72 

Lai, independently of the erectile states of the virile organ 
or clitoris.* 

■j The pudic nerve, through its reflex function, of which 
Jthe virile or genesiac reflex is an important part, makes 
possible erections, twitchings, jerkings, seminal emissions, 
scrotal retraction, etc. They are brought about through its 
influence and relations. Anatomists and physiologists have 
trome near to the discovery of the virile reflex before but 
just missed it, years ago. 

- If you suddenly stretch the foreskin or grasp and pull 
ithe glans penis toward the umbilicus of a virile individual, 
you will discover a sensible downward jerk of. the organ, 
land if you place one or two fingers of the other hand on 
the dorsum of the member, you will detect, by the sense of 
touch, the downward retraction, as plainly as you may see 
the plantar and toe reflexes after stroking your finger tips 
lacross the sple of the foot or metatorsal region. Both of 
these reflexes are normally downward. Or if, while hold- 
ing the organ slightly tense by grasping the glans around 
the corona, you jerk or pull the organ up toward the umbilicus 
and slap the inside of the thigh or sharply stroke upward 
with the finger tip the inguinal region over Poupart's ligament 
land the transversalis abdomis muscle, or if you forcibly 
pinch up the perineal integument of the perineal scrotum, 
•you will elicit the same downward retraction of the virile 
organ; appreciable to sight, but more so to touch. Or if 
jyou suddenly tap the penis with the same degree of force, 
the organ being rendered slightly tense, this downward jerk 
rhay be felt, even down to the perineal portion of the organ. 
The compressor urethra seems to contract and the bulbous 



* Certain fibers of the pudic nerve must be concerned in the production of the virile 
reflex that are not concerned in the erection or in bulbo-cavernous tumescence, because this 
'reflex can be elicited without necessarily having marked swelling or erection of the organ, 
though with great excitation both erection, vascular turgescence and the twitch of Onanoff 
appear. 



373 

urethra may be seen sensibly to enlarge, the dorsal and the 
'muscular branches of the pudic nerve seem to receive and 
"transmit the impression dorsad and return the peripheral im- 
pression transmitted into motion, in a true reflex manner, in 
which the compressor urethra and the bulbo-cavernosus 
portion of the penis participates, when the organ is erectile. 
Though this retraction may be easily elicited when the 
organ is not in an erectile condition. 

Erection is secondary, resulting from more extended 
penile excitation and not necessary to the display of this 
reflex sign of virility, though it may be and usually is. 

This is a true penile reflex, a true penis jerk, a true 
sign of virile intactness. 

The jerk is as plainly backward and downward as the 
knee jerk is upward, with a healthy spinal cord. It is not 
an erection, but a retraction, like that of the gullet reflex, a 
downward and backward jerk. There need be no erection 
accompanying this phenomenon and usually is none, though 
erection may come on through general pudic nerve excita- 
tion. It is more active in an erectile state of the organ 
and may be less active after a normal erection has 
been physiologically exhausted. It is in no sense a 
penis erection phenomenon, though absent when power 
of erection is absent or lost from genuine organic 
impotency, and is feeble in some cases or condi- 
tions of psychic impotence. To determine its value in 
pure psychic impotence and the genital weakness of sexual 
neurasthenia, demands more thorough study before abso- 
lutely positive conclusions can be reached thereon. I have 
seen it absent and very feeble in persons who subsequent- 
ly regained power, especially in sexual neurasthenia; in the 
prostration of typhoid fever convalescence and two of the 
spurious forms of tabes dorsalis — sexual exhaustion tabes — 



374 

DESCRIPTION OF FIG. 172 (OPPOSITE PACE). 

VL, IS, IIS, HIS, 1VS, VS, VIS. — Fifth lumbar, and first, second, thlr 

sacral nerves. 
LS, Lumbo-sacral cord. 

c, c % Posterior cutaneous nerves. 

m, Branches to muscles of back. 

1, Branches to pyriformts muscle. 

3, Muscular branches to obturator internus. 
II, llfo-lngutnal nerve, cutaneous, to Inguinal region and scrotum. 
GC, Genito- crural nerve. 

G, Genital branch to spermatic cord or round ligament. 
2, Muscular branch to cremaster. 

C, Crural branch, cutaneous, to surface of upper part of front thigh. 
EC, External cutaneous. 

P, Posterior branch, cutaneous, to upper and outer part of thigh. 

A, Anterior branch, cutaneous, to front of thigh. 

ps, Muscular branches to psoas muscle. 
AC, Anterior crural nerve. 

3, Muscular branches to illacus. 
3', Muscular branches to sartorlus. 
3", Muscular branches to pectlneus. 
fa, Branch to femoral artery. 

MC, Middle cutaneous to front of thigh. 

IC, Internal cutaneous to Inner part of thigh. 

LS, Internal or long saphenous. 

a, Cutaneous over inner ankle. 

/, Cutaneous to inner side of foot. 

4, Muscular branch to rectus femoris. 
4', Muscular branch to vastus externus. 
4", Muscular branch to crureus. 

4'". Muscular branch to subcrureus. 
4"", Muscular branch to vastus internus. 
A'/, Branch to knee joint. 
O, Obturator nerve. 

hj, Branch to hip-joint. 

<•'. Communicating with branches of internal cutaneous and internal 
saphenous. 

5, Muscular branch to pectineus. 

5', Muscular branch to obturator externus. 

6, Muscular branch to adductor longus. 
6'. Muscular branch to gracilis. 

6 ". Muscular branch to adductor brevis. 
6" 6 " '. Muscular branch to adductor magnus. 
AY. Branch to knee-joint. 
L. Communicating br.mch to fifth lumbar neive. 



375 



FIG. 172. 






-Ve*. 




376 

and malarial toxhaemia. 1 have also seen the knee jerk 
absent and recovered from in post malarial tabes dorsalis. 

This reflex downward jerk may be elicited by friction- 
ing the glans for awhile by rubbing it with a piece of pa- 
per (Onanoff's method) though I have never succeeded 
satisfactorily in eliciting it in this way until after the organ 
got into a state of erectile excitement. Eliciting it in this 
way not only excites erection, but it shows more as a twitch 
modification of this true virile reflex, than as the deliberate 
downward jerk 1 have described as the true virile reflex. 
This glans reflex friction method and the resultant twitch 
is the excitation method and the description of M. Onanoff, 
who made his discovery about the same time I made mine, 
as 1 learned when 1 communicated my discovery to M. 
Brown-Sequard, as 1 have stated in a former communica- 
tion on this subject; but you must note that the Onanoff 
discovery was complicated with erectile co-excitation and 
is therefore a complex phenomenon, and mine is not, and 
is not elicited exclusively in Onanoff's way of glans excita- 
tion, but chiefly and better in a different and less com- 
plicated manner. Mine is obtained in various ways and by 
penis upward traction reinforced by tapping or stroking or 
pinching in any of the genesiac areas of the body below 
the umbilicus. Onanoff called his discovery a bulbo- 
cavernous reflex twitch, caused by penile friction with a 
a paper or feather, while mine is a traction penile reflex, 
elicited when the foreskin over caput penis is drawn up- 
ward, as already indicated, if any nerve area of the 
inguinal, perineal or genital region is excited, as previously 
described, by either upward penis traction or by traction 
and tapping combined, or by tickling with a straw or by 
pinching or pricking certain areas. 

1 have seen it brought out when drawing up the caput 



377 

penis to introduce the catheter into the meatus or to get 
into the bladder under the pudic arch. 

This phenomenon has been in a manner vaguely and 
indefinitely known to anatomists and physiologists for sev- 
eral decades before 1 described it, or before Onanoff called 
attention to his similar phenomenon, but it has not before 
been separated from other penile phenomena and given the 
distinctive significance with which I invest it. Thus Am- 
brose Ranney, in 1881, reflecting anatomical observation on 
this subject up to the time of writing his treatise 
of that day on applied anatomy of the nervous system, 
called attention to the fact (Applied Anatomy of the Ner- 
vous System, 1881, page 469) that "in some cases of frac- 
ture of the spine, in the dorsal region, where a part of the 
spinal marrow is left intact below the seat of fracture, you 
may be able by repeatedly pinching the skin of the scro- 
tum and penis, to produce spasmodic contraction of the 
muscles of the perineum and urethra and often to effect 
turgidity of the genital organ to such a degree as to make 
it resemble an imperfect erection or priapism." This was 
an approach to and anticipation of M. Onanoff's bulbo- 
cavernous reflex discovery. 

It is not uncommon for vesical, as well as urethral, rec- 
tal and prostatic disease to produce sympathetic manifesta- 
tions in the genito-urinary organs in the form of neural- 
gic pains, involving involuntary emissions, incontinence of 
urine, etc., etc. Such effects can only be explained by the 
distribution of the pudic nerve to the integument about the 
anus and I believe, to the walls of the rectum also, which 
allows reflex motor impulses to be sent from the spinal 
cord in response to rectal irritation to the genito-urinary 
organs and perineal muscles. Now let us again run briefly 
over the subject of the pudic nerve and its relations for 



378 

explanation of the modus operandi of this remarkable reflex 
and its great value, which contributes further to make the 
pudic nerve in physiological significance, next to that of the 
wonderful vagus. 

To recapitulate: The virile reflex is lost, as you see, in 
impotence, impaired and lost in time by excessive venery 
and masturbation, this being Nature's inexorable remedy 
and punishment for prolonged and senseless sexual excesses 
and the conservation of normal vitality. It is excited in the 
early stages and lost in the later stages of posterior spinal 
sclerosis, the opium habit and extreme alcoholism. It wears 
out in the lascivious and bestial, and with extreme old 
age. It is excited in erotic hyperesthesia, in some stages 
of hysteria and in various influences, normal and morbid, 
coming from the rectum, urethra, testicles or ovaries and 
by descending influences, normal or abnormal, from the 
encephalon. 

1 admonish you again to maintain the integrity of your 
virile reflexes, gentlemen, in order that you may go through 
life a man among men and women and make a manly mark 
upon your day and generation. Be prodigal of its powers 
and you will be pigmies in the pathway of the giants you 
might yourselves be in your day and generation. The 
world is for the virile and strong. The weak in the pudic 
nerve and vagus nerve areas of the neuraxis go to the 
wall or are trodden under by those who better care for, or 
are better endowed in these vital reflex nerve centers and 
in their entire neuraxes. 



CHAPTER XXXII. 

Aphasia defined and located, aphasia physically and psychically 
considered. some of its most essential 
phases discussed. 



An important brain disease, often neurovascular or rather 
vasoneural in origin, but sometimes caused by tumor growths, 
gummata and other adventitia or by temporal bone frac- 
ture or concussion, involving a part of the brain in marked 
disorder, is aphasia or the alalia of Lordat, the asemasia of 
McLane Hamilton, the amnesia, etc., of other writers. This lo- 
calized brain disease has many varieties. 

The form of aphasia first discovered was that of lost 
power of speech formation and expression. That is the 
power in the mind to formulate ideas into speech language 
once possessed, but lost by disease of the speech center of 
the brain. In this disease there is a paralysis of word 
ideation power in the neurones of Broca's speech center. 

Bouillaud, as early as 1825, placed the faculty of artic- 
ulate speech in the frontal lobes of the brain and so had 
Gall before him and the elder Dax located the speech fac- 
ulty in the left side of the frontal lobes, while the junior 
Dax located the speech center in the left antero- lateral 
or middle lobe of the brain. 

It was reserved for Broca to still more definitely cir- 
cumscribe it in the posterior aspect of the third left frontal 

[379] 



380 

convolution. M. Broca had a patient at Bic£tre hospital, 
Paris, named Laborgne, who on admission, appeared intel- 
, ligent, but could not give his name or answer any question 
save with a gesture and the ejaculation tan tan and an auto- 
matically familiar oath in French. 

He had been epileptic from infancy, but had learned 
the trade of a last maker and followed it till about thirty 
years of age, when the loss of the power of speech dis- 
abled him from continuing his work." Ten years after admis- 
sion the power of his right side began to fail, and this weak- 
ness gradually extended to complete right hemiplegia and 
he became bedridden. There was no facial, tongue or voice 
paralysis and only the last act of deglutition was difficult. 

The patient became affected with phlegmonous erysip- 
elas of the right lower limb which, passing to the head, 
caused his death in six days. 

The post mortem revealed the dura and pia thickened, 
the latter injected, opaque and infiltrated, but not with pus. 
The greater part of the frontal lobe of the left hemisphere 
was soft and revealed a cavity the size of a hen's egg 
filled with serum in the lower marginal convolution of the 
temporo-sphenoidal lobe, the convolutions of the island of 
Reil and the extra-ventricular nucleus of the corpus 
striatum. In the frontal lobe the inferior part of the trans- 
verse (ascending) frontal convolution was destroyed and 
the posterior inferior half of the second and third frontal 
convolution, the greatest loss being in the third frontal. 

Broca reasoned from this case that the primary trouble 
was in the third frontal; that this primary disease extended 
to the other convolutions gradually and finally to the island 
of Reil and the extra- ventricular nucleus of the corpus 
striatum, when hemiplegia was complete. 

Broca had another patient named Lelong who, after his 



381 

aphasic seizure, named himself Lelo. Lelong had only a 
€inque verbe vocabulary consisting of oui for yes; non for 
no; 'tois 9 for trois (three) and toujours for always. His 
fifth word was Lelo, -for his name. Lelong was 84 years 
old. He had a fall on the stairs causing unconsciousness 
and apoplectic symptoms, but no paralysis. Intelligence re- 
turned to him with the coming back of consciousness, but 
not the power of speech beyond what we have noted. He 
used oui, non and Lelo definitely and intelligently. Tois 
referred to any number, not specially to three, and toujours 
for every other word idea. 

Lelo was an octogenarian, who in I860, while descend- 
ing a stairway, fell unconscious and was treated for apo- 
plexy, but in a few days he became convalescent without a 
sign of limb paralysis, but with the attack he had lost the 
faculty of speech except in the limited, crippled and bizarre 
manner above stated. His intelligence appeared intact 
through the limited vocabulary which he articulated with 
difficulty, but made clear by an expressive facial mimicry, 
to those accustomed to be his audience. 

This case, more than any other in M. Broca's expe- 
rience, converted him from the skepticism with which he 
had challenged M. Aubertin to the proof, not long before, 
of an anterior convolution center for speech lesion, to abso- 
lute conviction and to the definite area of the third left 
frontal convolution, which now bears the name of Broca's 
speech center. 

Lelong, less than 18 months after his aphasic attack, 
had the misfortune to fracture the neck of his femur at the 
age of 84 years, from which death resulted twelve days 
after the accident. The autopsy of Lelong revealed in the 
left hemisphere a lesion limited to the posterior third of the 
second and third frontal convolutions. A small cavity filled 



382 

with serum was found there. The right hemisphere was 
sound in the corresponding locality, the pia and dura were 
found normal, the arachnoid held a considerable quantity of 
serum; the right hemisphere, the cerebellum, pons and me- 
dulla were healthy. Only the left hemisphere showed 
the lesion limited to the posterior third of the second and 
third frontal convolution. 

Remarkable revelation! An old man whose race on 
earth is run, by a fortuitous accident, reveals in his death 
a secret which the ages have kept hidden. Broca, a genius 
of our great profession, a son of France, discovers it by the 
light of that same necroscopic science shining in another 
age, which made the great, the sublime Vesalius immortal. 

These cases were convincing evidences to Broca of a 
speech center about the island of Reil. The case of Lelong, 
especially, clinched and confirmed his convictions of the in- 
sular speech center, which now bears his name. This em- 
inent and immortal clinician thus summed up the case of 
Lelong: Lelong understood all that was said to him, he 
applied with discretion the four words of his vocabulary; (five 
words, for his name Lelo was one) ; his intelligence was 
unimpaired; he understood numbers and had neither lost 
the general faculty of language nor the power of moving 
the muscles of speech and sound, but only the faculty of 
articulate language. 

Since Broca's discovery, investigators have found and 
named many varieties of aphasias depending upon con- 
nection and lesion of other centers in the brain. Amnesia 
or amnesiac aphasia, such as the loss of the memory 
of spoken words, agraphia or agraphic aphasia, the loss of 
memory tor written words, sometimes separately, and some- 
times both together lost. Kussmaul, Tenner and especially 
Wernicke, at later dates, associated the hearing centers of 



383 



the temporal convolutions with the speech center of Broca, 
and the term "word deafness" was born. Ferrier, Hughlings 
Jackson, Broadbent, Horsely and other later investigators 
have contributed to extend the aphasia area, the center of 
its^expression, however, remaining where Broca located it. 

FIG. 173. 
CjhorcdCi QrWxnoX P\*gram ov Qra\ avid 




I C, Ideational Centre. 
C A C, Common Auditive Centre. C V C, Common Visual Centre. 
A C W, Auditive Centre of Words. V C W, Visual Centre of Words. 
C A L, Centre of Articulate Lan- C W L. Centre of Written Lan- 
guage, guage 

The pen and hand expresses impression of bell in writing, or in panto- 
mime or both. The mouth in oral expression or aids in pantomime. 

The sight or sound impression of a bell goes from the 



384 

eye or ear to visual or auditory centers in the brain and is 
received there and transmitted as a bell idea to the speech 
or language conception and expression center, as the let- 
ters on the bell diagram of Charcot are intended to show. 
The next diagram, one of Langdons, is more elaborate and 
explicit and makes this subject still plainer. Nearly every 
one, from Wernicke to Broadbent, Hughlings Jackson, 
Horsley and Langdon, has made some sort of a diagram on 
the blackboard similar to the one I have hastily made with 
the crayon. But 1 prefer not to reproduce my own, since 
you can have it at every lecture. 

If you will recall what I have said in previous prepara- 
tory lectures on the association of the brain, how one cen- 
ter is brought into connection with another center there, by 
means of projection and communicating fibers in the brain, 
you can work out the scheme of the many possible varie- 
ties of aphasia for yourself. Thus you would work out au- 
ditory aphasia or loss of the memory of word sounds, vis- 
ual aphasia or loss of the memory of word characters. 
Pantomime memory loss would be a variety of this form of 
aphasia or loss of the sign memory of words and things. 
There is also an aphasiac affection associated with taste, 
smell, touch centers, etc. As in brain disease, especially 
some forms of subfrontal tumor and in epilepsia and 
syphilis, patients have hyperosmia, so they have anosmia 
and other smell perversions from the same cause and in 
connection also with aphasia. There are also taste and 
smell expression failures in aphasia. 

But I can not go at length into this subject. 1 can 
give you only the key note, as it were, of the aphasia song. 
When you have leisure you may take the key and unlock 
the manifold treasures on the subject to be found in the 
treatise of Hughlings Jackson, Horsley, Beevor, Bastian, 



385 

Bateman, and the monographs of Langdon, Hinchelwood, 
Eskridge, Ross, Seguin, Mills and many others. 

Langdon has called attention to the existence, as yet 
unrecorded except by himself, of word anaesthesia, panto- 
mime blindness and pantomime forgetfulness in connection 
with this subject, and Mills to loss of object memory, as 
distinguished from loss of name memories. Both of these 
distinctions may interest you later. They all come under the 
general name of aphasia (a-phasis, speech); absence of speech 
memory, which includes any and all of its varied expressions, 
whether written, oral, gestured or otherwise pantomimed. It 
includes derangement of the memory of speech, song, 
mimic, gesture or written character expression, one or sev- 
eral, but not all of these forms of expression and comprehen- 
sion of word ideas at the same time. If all the avenues of 
speech idea impression and expression are destroyed in the 
brain, we then have no way of determining if pure aphasia 
exists. A much more extensive brain area than that con- 
stituting the group of neurones, making only the speech 
center of Broca, may be involved in aphasic disease, 
(Broca's area being the central speech depot, the brain's 
hello- girl, so to speak, of the central phone office). 

Aphasia then, in its most comprehensive sense, means 
loss of sign or language power construction (singing, speak- 
ing, shouting, gesture, language, perceptive or constructive), 
expression in the cortex of the brain, arising from disease 
there. 

More specifically expressed aphasia means a loss of the 
power of written or sign or sound perception or conception, 
or expression, one or more of these defects caused by dis- 
ease involving the third left frontal convolution are of the 
brain. More briefly yet, it is a derangement of the word 
or sign idea center of the brain. 



386 

Aphasia is usually caused by embolic instruction of the 
left middle cerebral artery or its branches to the speech 
center of Broca in the third left frontal convolution. The 
first branch being the one chiefly and most usually in- 
volved in aphasia. 

Aphasia may also result from an apoplectic blood clot, 
a thrombus, a tumor, an exudate or an abscess involving 
the speech center, or a wound of the temporal region of 
the skull may cause it, or a pernicious anaemia with or 
without blood extravasation. A cranial traumatism elsewhere 
may indirectly implicate this important brain center. It may 
also result from epilepsia major or epilepsia minor, or tem- 
porarily follow an attack of epilepsia gravior. An attack of 
hysteria or violent psychic shock may cause it. The person 
in the latter instance is then said to have been stricken 
dumb. 

Stage fright sometimes develops it so that one entirely 
forgets his part. It may therefore be both functional and 
-structural in its cause and both transient and permanent in 
its duration. 

Aphasia is strictly a focal disease of the brain, as 
much so as a Jacksonian epilepsy caused by a tumor, 
pressing upon a single psychomoter center. It is a local 
disease, as distinguished from a general disease of the 
brain, impairing the capacity to speak, not dependent upon 
any lesion in the pons or medulla or of any nerve coming 
out therefrom. 

The power of speech is destroyed in coma and in 
paralysis and in glosso-labio-laryngeal paralysis, etc., but 
these states are not true aphasia. To constitute true 
aphasia the speech center must be chiefly, almost exclusively 
involved. Aphasia is essentially a speech center disease, 
involving the brain here and the intermediate neighboring 



387 

avenues of word, sound or character impression leading to 
or going from it. The keys or strings for the performing 
speech-making neurones of the word or sign center instru- 
ment in the brain, must be out of order to constitute a case 
of aphasia. Something is wrong with the aphasic's con- 
nection with the telephone girl or with the central girl 



LANGDON'S DIAGRAM OF APHASIA AND ITS SUBCORTICAL RELATIONS. 

FIG. 174. 



^Cs ijck* c Carte* 




herself. You call up the speech central, but get no satis- 
factory answer. Something is wrong there or on the way 
there or from it. The fault is at the center or in the con- 
necting neurones. 

Aphasia should not be confounded with aphonia, or 
the latter mistaken for the former. Aphonia is a loss of 
voice from paralysis of the voice-forming muscles of the 



388 

larynx and glottis, with the epiglottis sometimes included, 
either in their peripheral nerves of innervation or at the 
origin in the medulla, of these nerves. Speech may also be 
affected through damage to the labial and tongue, as well 
as voice innervation nerve areas and nerve tracts, whose 
source is also in the medulla. Another set of nerve center 
keys or neurones and strings or nerves, are brought into 
action in this process of regulating the caliber and sounds 
of the larynx or voice pipe of the mind for communicating 
with the outer world. 

Aphasics can therefore utter sounds and exclamations 
and they often use a certain sound or combination of sounds 
with very different and sometimes very reverse meaning 
from the. ordinary. Bevin, as you see, could only say nin- 
nin for yes or no or any sort of affirmation or negation. 
One of Bastian's said bi-bibi, poy-coy-ba and no, learning 
after fifteen months to say yes and no appropriately. Ham- 
mond reports an aphasic who said "what! certainly — saw 
my leg off" in answer to any question. Prof. Lordat, de- 
scribing his own aphasia, could only use a single exclama- 
tion and Trousseau, who reports the case of Lordat at 
length, records the case of a lady who on receiving a visi- 
tor would exclaim, pig-brute-stupid-fool, meaning "Monsieur 
or Madame, please be seated." The impropriety of this un- 
complimentary antithetic salutation was not recognized in its 
enormity by the speaker, who supposed she was saying 
the right thing, for "she would smile sweetly upon her 
guest while saying it, and in her most charming manner 
offer her visitor a chair." There is always a lesion of 
connection with the center of word audition in these cases. 

Another patient of the brilliant Trousseau would, when 
at her devotions, utter this antithetic sentence, "Our 
Father which art in Hell." There is a sort of seeming 



389 

psychic blindness to the proprieties in some cases. The 
patient will go on after these outre and bizarre expressions 
as if they were perfectly proper. In such cases there is 
some lesion in the auditory center relation, as 1 have said, 
as there is in the visual relations when they write the 
wrong words or spell words incorrectly. They know how to 
spell but do not recognize the error. The lesion may be 
limited to auditory center connection when the case is one 
of aphasia only, or there may be a general lesion in the 
understanding. In the latter case you have insanity with 
aphasia or aphasic insanity. 

Charcot had a woman patient who said ta, and ta-ta- 
ta-ta, which was all she could say, a great hardship for a 
woman, but she meant everything by it. 

A few more illustrations must suffice and then we must 
pass to discuss briefly another very practical and important 
aspect of aphasia, viz.: its medico-legal features, for aphasia 
is not insanity, it is not apoplexy, it is not epilepsy, 
though it is sometimes an associated feature of these dis- 
orders of the brain. To enlighten the law on the differ- 
ence is the province of the neurologist and alienist. The 
law needs much light on the subject. Law may learn much 
here from the medical profession. 

Lesions of the brain have been found, as we have al- 
ready seen, in the right insular area, in the left-handed 
and in the ambidextrous persons from the time of Andral, 
Trousseau and the earlier clinicians and pathologists to the 
present day, and where the lesion had been a correspond- 
ing one on the right side, it has not been proven that the 
victim was not either right or double-handed or both. 
Bateman cites three cases from Velpeau, of aphasia con- 
nected with right side lesion, but they do not say whether 
the patients were right or left-handed or ambidextrous. 
Bateman also cites a case from Velpeau to show how irri- 
tation of disease in the left speech center vicinity may 
cause irritable loquacity, but 1 can not take your time to 
recount it at length. 



FIGS. 175 AND 176. 




(TtMt r | 

t« Ttji. - J. *rt«ro 4vttim6t «u lobo or'.m»irt. — I, 

infer » UfWfl), •!, 4 .,,,.;.. i, .,,■ ii| .-. 



1, trunk of middle cerebral; 2, artery to orbital lobe; 3, inferior frontal 
artery to third left frontal or Broca's speech center convolution; 4. ascend- 
ing frontal convolution arising from *>, a branch Irom the common trunk of 
the Sylvian; 6 t ascending parietal artery, Other figures show arterial dis- 
tribution of Sylvian branches to neighboring areas of the brain, including 
ascending parietal, frontal and temporal convolutions. From Raymond* 
"Clinique" on "Disease of the Nervous System." 

Fig. 1, 2, 3, F«, first, second and third frontal convolutions; 1. 2,3,T. t 
first, second and third temporal; 1 and 2 P; first and second parietal; 1,2, 
3, 0, the three occipital convolutions. # 

Culsse, thigh; Jambe, leg; Hanche, hip; Tronc, trunk; Epaule, shoulder; 
OrtelJs, great toe; Pied, foot; Conde, elbow; Poiguet, wrist; Doigts, fin- 
gers; Pouce, thumb; Language center, muscles of the face and mastication. 



391 



FIG. 177. 



(K.\p/C*5,rtv/tA*s, Kpu<oc, L.C\rcus,CvYcxxWs, 
r cl circle ©^ UVtte c\rcU) 




CA — Anterior cerebral, CAA — Anterior communicating cerebral, CM — 
Middle cerebral. CI— International carotid, COP — Posterior communicating 
carotid. OPO — Posterior cerebral, CBS — Superior cerebral. CBIA— Anter- 
ior inferior cerebellar. AUD— Interior auditory, BA - Basillar artery. V — 
Varolian. CHIP— Posterior inferior cerebellar. SPA— Anterior spinal, SPP 
P— Posterior spinal. 



CHAPTER XXXIII. 

THE MEDICO-LEGAL ASPECTS OF APHASIA. 
THE CASE OF WM. T. BEVIN. 



As 1 have said, aphasics will often be suspected of in- 
sanity and it may be your professional duty some day, in 
the line of your observation, to differentiate between the 
loss of power of speech conception and expression, and the 
loss of mind. 

For your further enlightenment on the subject, 1 here 
give you briefly a medico- legal case in which this question 
was asked of me, as a psychological expert, in a St. Louis 
court. 

It was the case of Wm. T. Bevin,* an Inquiry into 
the question of aphasia or insanity; a hemiplegic re- 
recovered with aphasia remaining. Following is the psy- 
chological expert analysis and opinion rendered on the 
witness stand in non-technical language and manner of 
analysis, so far as was practicable, at the October, 1878, 
term of Circuit Court No. 2. 

The title of this case on the records is Wm. T. Bevin 
vs. Powell. 

On the thirteenth of March, 1873, Mr. Wm. T. Bevin, a 



♦The substance of this paper was read before the Association of Medical Superin 
tendents of Asvlums for the Insane, at Washington, D. C . May 17. 1878. and published 
In the American Journal of Insanity for that year under the title of " Aphasia or Aphaslc 
Insanity. Which?" 

[392] 



393 

builder, a few months after the death of his wife, was stricken 
with right hemiplegia and aphasia. A cardiac valvular 
lesion preceded the paralysis and persisted to the time of 
my last examination, February 7, 1876, and to the time of 
his death, several years after. His respirations were 
twenty-one per minute, lungs were healthy, heart and 
wrist pulsations asynchronous, the latter counting as high 
as one hundred and eight, and the former sometimes ten to 
eighteen more, per minute. At this time there was incom- 
plete paralysis of motion on the right side and general 
anaesthesia. He was insensible to the pricking of a pin in 
both hands and feet. The sub-lingual temperature, on 
either side, was 98° F. He correctly and promptly com- 
prehended oral signs, but tardily and imperfectly understood 
written ones. He soon recognized my name and wrote it 
for me, witli his left hand. He likewise wrote his own 
name and the surname of his attorney (Mr. Rainey), 
upon my asking them. An H, written by myself, and an 
imperfectly erased tracing of my surname, were on the 
card on which he wrote my name. He first attempted to 
attach "ughes" to the H, 1 had written, but afterwards 
changed his mind and made an H of his own, which ac- 
counts for the somewhat disjointed appearance of the word 
Hughes, here following: 




His tongue was clear, but he said he always had a 
disagreeable taste in his mouth. He either really had, 
or feigned defective vision. When the thumb was held up 



394 

before him, looking with one eye, the other being blind- 
folded, he would say it was two, and when the thumb and 
little finger were held up, he would say there were three. 
1 intended making an opthalmoscope examination, but be- 
fore I had opportunity the case came to trial, and my tes- 
timony not being satisfactory to the family, I did not offer 
to examine him further. He had defect of hearing in the 
left ear, which 1 thought feigned at the time, but which I 
later concluded was a fact, as it was in harmony with his 
aphasia and evidently resulted from the blood pressure 
disturbance in the neighborhood of the hearing center of 
the brain, affecting the auditory conducting paths to 
Broca's center on that side. He signed that he could not 
hear the ticking of a watch half an inch from his ear, yet 
he distinctly understood a remark to him by his sister in 
quite an ordinary tone, at least twelve feet off from him, 
at the time I was testing his hearing with the other ear. 
None of his family spoke to him in a very high tone, as is 
customary when one is deaf. He repeated the word nin- 
nin, accompanied by bowing or a nod of the head, to sig- 
nify yes and by a turning to left and right to indicate no. 
When 1 wrote W. T. Bevin and asked if that was his 
name, he shook his head and taking the pencil wrote 
Wm. T. Bevin: 

He had three paralytic strokes, and was seen by 
his relatives after each attack. He grew steadily better 
in mind after the first attack, notwithstanding the subse- 



395 

quent attacks which were slighter and more transient than 
the first and displayed a singularly exceptional knowledge 
of the details of his business affairs and signed with his left 
hand an intelligent and business agreement with regard to 
some houses he was building jointly with some other par- 
ties, and in fulfillment of a promise and purpose, made and 
entertained prior to his attack. He could not write with 
his left hand before he was stricken. About the same time 
of, and prior to the signing of this deed of trust, he is said, 
by some of the members of his family — principally his two 
sisters and a brother-in-law with whom he lived — to have 
done some things which they swore they regarded as evi- 
dence of insanity, such as on one or two occasions (none of 
the witnesses testifying to more) bowing to pictures in the 
parlor, when he knew members of the family were present, 
and with a pleased but silly appearing smile; one side of 
his face being defective from paralysis. Once he is said 
to have wiped his nose on his napkin, and one or twice, in 
the early stage of his paralysis, they say he spat on his 
plate. Once he unbuttoned his drawers when his sister 
and another lady were in the room. It was said that once, 
after his first stroke of paralysis, he defecated in bed. 
[Once, he is said to have struck his mother with a stick, 
though one of his brothers, who swore there would have 
been no suit if he had got his three per cent, commission, 
as promised, for taking his afflicted brother's interest in the 
business, said he never saw or heard of such an affair, or 
of unbecoming conduct of any kind toward her. 

Some or most of these acts were natural enough to his 
paralysis, as it was also natural to bow to the crucifixion 
and other objects when asked to point them out.] At this 
time he could not, the family say — all but one brother — 
distinguish letters or tell if they were upside down or not, 



396 

but readily recognized them if their names were called. As 
early as the first of May, in 1873, he could sit in a chair 
and get about the room. In June he appeared to one of 
his physicians to be silly, "because he smiled peculiarly" 
and was exceedingly violent and irritable when the battery 
was applied. To another of his physicians he appeared de- 
mented, though he was able to go unaccompanied in the 
following November, a long distance, to this physician's 
office, correctly select and count his money and pay his med- 
ical bill, and take and put away carefully a receipt for the 
same. It was also said that he made grimaces before a 
glass once or twice, and pulled out his hair, and he ate 
things when set before him, that he never ate before. He 
handled his food with his fingers (he could not use a 
knife and fork), and his manners and tastes at table were 
changed in some other respects, he having been formerly 
very fastidious and precise. 

When he first learned to write his name he would 
make signs to visitors for a slate, write his name for them, 
and express his pleasure at the accomplishment by a peculiar 
smile. After the description of his property, mentioned in 
the deed of trust, was read to him, he pointed in the di- 
rection of it and gave an assenting nod, pointing immed- 
iately after in the direction of other property not alluded to 
in the document, and indicating his understanding that it 
was not included, by the usual turning away of the head 
indicative of dissent. 

He was attended by different physicians during the 
first attack. The physician who first saw him at the time 
of his first seizure found him only partially paralyzed on 
the right side, with consciousness still remaining, and 
helped him home. In six hours after this physician saw 
him, he was hemiplegic and unconscious, and so remained 



397 

for several days. He commenced to improve in two or 
three weeks. He was then annoyed by movements about 
the room and exhibited "not much, but some signs of in- 
telligence in his countenance. " He made signs and efforts 
to convey ideas, and would mumble unintelligibly in an- 
swer to questions and had difficulty of deglutition. He 
never, at any time, had delirium, delusion or hallucination. 
He recognized Dr. Mudd generally when he visited him. 
One attending physician thought his mind was impaired, 
because "there seemed to him to be an absence of power 
of expression and clear conception of subjects." This was 
just after the stroke. This mental confusion was a natu- 
ral concomitant of the great commotio cerebri incident to 
such a severe, extensive and sudden involvement of a cer- 
ebral hemisphere in disease, even though that disease were 
only an embolism of the middle cerebral artery. He might, 
at this stage even, have been demented, as he was con- 
sidered to be, later, by one of his physicians but it could 
not be the real and permanent dementia which results from 
general degeneration and destruction of the cerebral cortex, 
as the improvement which soon began to appear and all 
the sequelae — his learning to write with his left hand, rec- 
ognizing and designating friends, pictures, etc., within four 
months, conclusively proved. All the symptoms pointed to 
middle cerebral artery embolic obstruction. 

When we reflect that his hemiplegia embraced one-half 
of his face in paralysis, simulating a Bell's palsy, it is not 
strange that he should have appeared silly and smiled 
peculiarly in May. He being irritable and violent when the 
battery was applied at that time, indicates only that the 
degree of paralysis of sensation has increased since then. 
It is not strange that he could not distinguish letters or 
tell if a book or paper was upside down, confusion of vision 



398 

being the rule rather than the exception, after hemiplegic 
strokes and cerebral embolism. The length and position 
of the optic chiasm, tractus opticus, and of the optic 
nerve within the brain, and the manner in which they 
are placed and surrounded with blood vessels, expose the 
apparatus concerned in sight to great disturbance of 
function from pressure, etc.; for this reason various 
disturbances of vision are common in morbid condi- 
tions of the brain. This patient might have been totally 
blind from pressure consequent upon the cerebra oedema, 
which generally follows embolic closure of a vessel in other 
parts of the brain than the spot primarily implicated in the 
embolism, if we take no account of possible similar, sim- 
ultaneous closure of other arteries of the brain. 

In regard to dementia, which only one of his physicians 
asserted that he had (Dr, Benkendorf), it is difficult for the 
practiced alienist and neurologist, accustomed to observe the 
phenomena and progress of this profound form of mental 
disorder, to conceive how a patient could have really been 
demented in June, in consequence of a cerebral vascular 
lesion grave enough to cause hemiplegia, paraplegia, con- 
fusion of vision and aphasia, and yet, be so recovered by 
the next following November, as to fully appreciate the 
services he had received from his physician, and go unac- 
companied to his office, and settle in an intelligent manner 
his bill, even though ht> could not speak. 

It was singular that of all the acts testified to by Bev- 
in's brother-in-law and sisters, who were living with him 
and interested in the success of his suit, none of them 
should have been observed more than once or twice during 
the whole time of his affliction. Many of these acts, 
had thev o*vutied ottener, would have been explicable other- 
wise than on the theory of insanity, and all of thent, as 



399 

the testimony gives them in this case, are; explainable with- 
out invoking the presumption of insanity. I have seen my 
own little son study the play of his facial muscles in a glass, 
and when 1 was a student of anatomy 1 did the same thing, 
before a mirror, too. 

The circumstances connected with the once wiping of 
his nose on the napkin or table-cloth do not appear. He 
wiped his nose once or twice. It was not shown that he had 
a pocket-handkerchief, or that he had ever used his napkin 
in lieu of a handkerchief before his affliction, or that he 
did not do it to annoy, rebuke and chagrin those who 
should have given him a handkerchief. 

[ In the next lecture we will conclude the record of this 
subject.'] 



CHAPTER XXXIV. 



PSYCHOLOGICAL ANALYSIS OF THE BEVIN CASE CONCLUDED. 



None of these acts indicated mental incapacity on the 
part of Bevin. Another medical gentleman of large practical 
experience *with the insane, no less eminent in psychiatry be- 
fore the courts and in my own esteem, concurred with me in 
the opinion that these acts occurring before the signing of 
the deed — some of them, as the bowing to pictures, etc., 
within a month or two— did not indicate sufficient mental 
impairment to disqualify him for a full appreciation of the 
nature, quality and purport of the transaction. 

In this case, I think, there was mental impairment only 
to the extent of a crippled power of speech expression. There 
was impairment of executive (not reflective) mental power to 
such a degree as to incapacitate the individual from profitably 
engaging in the pursuit of his avocation, after he had fin- 
ished up the business which occupied him before his 
affliction. Mr. Bevin seemed himself cognizant of this fact, 
and conducted himself after his affliction strictly in har- 
mony with his surroundings, till his death. He learned to 
write his name with his left hand, attached his signature 
to an important document, as it was necessary for him to 
do in order to complete the undertaking he had been en- 
gaged in, and after that signed no more documents, nor at- 
tended in person to any business, but relied on the proxy 

[400] 



401 

of his next friend. He knew he was disabled for business 
by his incapacity to properly express himself and use his 
mind as he should, just as a man with a sprain or broken 
limb refrains from walking or a business that requires 
sprinting, and this knowledge and this fact and his actions 
in conformity thereto, are proofs of his sanity. 

Let us look at his acts and see how far they tend to 
establish insanity. In the first place they are limited in 
number, not a single habitual action appears in his history 
that is at all singular. He defecated once in bed at the 
time it is testified by his family physician that he was first 
paralysed. (This was certainly an accident due to his 
paralyzed condition at a time when no one was present to 
assist him, and not the result of mania. This accident was 
not repeated.) No one was present at the time it occurred. 
Maniacs have often filthy habits long continued. Accidental 
occurrences of this kind are seldom, if ever observed. (De- 
ments often and habitually defecate in bed or in their clothes, 
unless specially attended to.) The spitting in his plate once 
or twice before he had learned to so co-ordinate the damaged 
muscles of oral expulsion, or to adapt his position at the 
table to the changed circumstances of disease, was due to 
the facial paralysis rather than insanity. 

Then as to his irritability. Recovering paralytics and 
aphasics are often irritable, and not very reasonable at all 
times when irritated. They can not make their many wants 
understood, and while they understand themselves well, can 
not well understand why those about them do not compre- 
hend their gestures and grimaces more readily. That he 
should once strike his mother, under such circumstances, 
does not then appear as an act of insanity. He was at 
first an irritable, childish paralytic, but gradually improved, 
and never struck her again. He did not attempt to 



CHAPTER XXXIII. 

THE MEDICO-LEGAL ASPECTS OF APHASIA. 
THE CASE OF WM. T. BEVIN. 



As I have said, aphasics will often be suspected of in- 
sanity and it may be your professional duty some day, in 
the line of your observation, to differentiate between the 
loss of power of speech conception and expression, and the 
loss of mind. 

For your further enlightenment on the subject, I here 
give you briefly a medico -legal case in which this question 
was asked of me, as a psychological expert, in a St. Louis 
court. 

It was the case of Wm. T. Bevin,* an Inquiry into 
the question of aphasia or insanity; a hemiplegic re- 
recovered with aphasia remaining. Following is the psy- 
chological expert analysis and opinion rendered on the 
witness stand in non-technical language and manner of 
analysis, so far as was practicable, at the October, 1878, 
term of Circuit Court No. 2. 

The title of this case on the records is Wm. T. Bevin 
vs. Powell. 

On the thirteenth of March, 1873, Mr. Wm. T. Bevin, a 



♦The substance of this paper was read before the Association of Medical Supertn 
tendents of Asylums for the Insane, at Washington, D. C . May 17. 1878. and published 
In the American Journal of Insanity for that year under the title of "Aphasia or Aphasic 
Insanity. Which?" 

[392] 



393 

builder, a few months after the death of his wife, was stricken 
with right hemiplegia and aphasia. A cardiac valvular 
lesion preceded the paralysis and persisted to the time of 
my last examination, February 7, 1876, and to the time of 
his death, several years after. His respirations were 
twenty-one per minute, lungs were healthy, heart and 
wrist pulsations asynchronous, the latter counting as high 
as one hundred and eight, and the former sometimes ten to 
eighteen more, per minute. At this time there was incom- 
plete paralysis of motion on the right side and general 
anaesthesia. He was insensible to the pricking of a pin in 
both hands and feet. The sub-lingual temperature, on 
either side, was 98° F. He correctly and promptly com- 
prehended oral signs, but tardily and imperfectly understood 
written ones. He soon recognized my name and wrote it 
for me, witli his left hand. He likewise wrote his own 
name and the surname of his attorney (Mr. Rainey), 
upon my asking them. An H, written by myself, and an 
imperfectly erased tracing of my surname, were on the 
card on which he wrote my name. He first attempted to 
attach "ughes" to the H, I had written, but afterwards 
changed his mind and made an H of his own, which ac- 
counts for the somewhat disjointed appearance of the word 
Hughes, here following: 




His tongue was clear, but he said he always had a 
disagreeable taste in his mouth. He either really had, 
or feigned defective vision. When the thumb was held up 



394 

before him, looking with one eye, the other being blind- 
folded, he would say it was two, and when the thumb and 
little finger were held up, he would say there were three. 
1 intended making an opthalmoscope examination, but be- 
fore I had opportunity the case came to trial, and my tes- 
timony not being satisfactory to the family, I did not offer 
to examine him further. He had defect of hearing in the 
left ear, which 1 thought feigned at the time, but which I 
later concluded was a fact, as it was in harmony with his 
aphasia and evidently resulted from the blood pressure 
disturbance in the neighborhood of the hearing center of 
the brain, affecting the auditory conducting paths to 
Broca's center on that side. He signed that he could not 
hear the ticking of a watch half an inch from his ear, yet 
he distinctly understood a remark to him by his sister in 
quite an ordinary tone, at least twelve feet off from him, 
at the time I was testing his hearing with the other ear. 
None of his family spoke to him in a very high tone, as is 
customary when one is deaf. He repeated the word nin- 
nin, accompanied by bowing or a nod of the head, to sig- 
nify yes and by a turning to left and right to indicate no. 
When 1 wrote W. T. Bevin and asked if that was his 
name, he shook his head and taking the pencil wrote 
Wm. T. Bevin: 



/ 'K/i_ v 




** ^^/)hU^ 



He had three paralytic strokes, and was seen by 
his relatives after each attack. He grew steadily better 
in mind after the first attack, notwithstanding the subse- 



405 

made independently in different directions, and by different 
persons. It seems to agree, moreover, with clinical and pa- 
thological evidence,"* Dr. Hughlings Jackson and other au- 
thorities on the subject of brain disease agreeing with him. 
The above expert opinion and report was, with a few 
interlineations, marked in brackets, given and made in 
1879, while Bevin was still living in the healthy enjoyment 
of ordinary intellection, all except the oral aphasia. 

The examination of this case was made, as you will note, 
over a quarter of a century ago, when I had less knowledge 
of aphasia and its many forms than has been discovered 
since, or than the world knew. Although clinically it was 
known to Benjamin Rush and even to Hippocrates, prob- 
ably, it was only as late as 1861 that those distinguished 
lights in French medicine, Messieurs Gratiolet, Aubertin 
and Broca were disputing its location as maintained by Bouil- 
laud, in the anterior lobes, before the Anthropological Society 
of Paris, and only a short time before that that the Daxes 
were contending for a place for it in the fore- brain frontal 
lobes. This memorable year of 1861, memorable in France 
for science, in our own country for war, M. Broca announced 
his conversion, after a famous autopsy performed by him- 
self, to the third frontal lobe theory of the younger Dax, 
and in his conviction further circumscribing the location of 
aphasia to that portion of the third frontal convolution, that 
now bears his immortal name. 

Apropos of our subject, are some observations on cerebral 
thermometry in aphasia. Before the Paris Academy of Medi- 
icine, December 30th, 1897, M. Broca** made the following 
remarks upon local cerebral temperatures: Finally, in cere- 
bral affections, in aphasia and the paralysis which may be 

♦Bastian on Paralysis, from Brain Disease, p. 239. 
**Ga&tU de$ Hopitaux, January 3d, 1880. 



406 

caused either by an embolus in the Sylvian artery or by an 
acute or chronic encephalitis of the cerebral region which 
surrounds that artery, the employment of a thermometer 
permits a diagnosis which the identity of the symptoms 
would render otherwise almost impossible. In fact, in 
case of embolus of the Sylvian artery, the temperature 
which is found lowered in the temporal region, is found, on 
the contrary, quite notably increased at the frontal region, 
and sometimes even also a little at the occipital region. 
This depends upon the fact, that the re-establishment of 
the circulation in the region which ceases to be supplied 
by the Sylvian artery takes place, principally, by the anas- 
tomoses of this artery with the vessels which nourish the 
anterior part of the frontal lobe, and, in proportion, much 
less by the posterior anastomoses of the Sylvian. 

In the cerebral softening by encephalitis, we observe 
something analogous. If the encephalitis is acute, the temper- 
ature is notably increased in all the part affected; if the 
encephalitis is chronic, the differences are less appreciable, 
but always of the same kind. 

Encephalitis is not susceptible generally of being 
treated by surgical means. There is, however, one case 
where the surgeon may be called upon to interfere, and 
with great advantage; it is when following a depression of 
the cranium, some bony fragments, irritating the cerebral 
substance, produces sometimes long after the injury, such 
accidents as symptomatic epilepsy, etc. If then the tre- 
phine is applied, the epilepsy ceases, once the cause has 
been removed. In such a case we find that the tempera- 
ture is elevated at the point where it is best to apply the 
trephine. 

M. Broca used an ordinary thermometer in making 
these researches, covering over the bulb with a sort of hood 
and waiting till the column became stationary. 



CHAPTER XXXV. 



THE NEURAL AND PSYCHO-NEURAL ASPECTS OF SURGICAL PRACTICE. 



Surgeons have long known the significance of knee 
pain in hip-joint disease through neural knee-joint connec- 
tion. The importance of the nervous system in its relation 
to surgical diagnosis had a forceful exemplification in the 
case of the lamented President Garfield when that persis- 
tent pain in his toe and foot, which the distinguished pa- 
tient complained of, was spoken of daily by him, without 
due notice being taken thereof by his surgeons, as refer- 
ring (which it did) to its source of anatomic irritation in 
the lower lumbo-sacral spine, where a vertebral injury was 
discovered post-mortem, as having been in the track of the 
assassin's fatal bullet. (Tarsal branches, anterior tibial; 
branch of the external popliteal; branch of sciatic, origin 
of sciatic (great) lumbo-sacral spine, sacral plexus, 1st, 2d, 
3d and 4th lumbar; 1st, 2d and 3d sacral) That great 
operation on the nervous system, trigeminal gangliectomy, 
for which Spiller and Frazier now propose division of the 
sensory root within the cranium for tic doloureux, as a 
substitute for all other operations on the Gasserian ganglion, 
reminds us also how closely in touch are neurology and 
surgery, and the latter improved results, according to 
Krause and Carson's records for Gasserian ganglion excis- 
ion, show the conjoined benefits of improved surgical technic 

L407] 



408 

and advanced neurotherapy. The screening of the eye 
alone does much more to save the central nervous system 
than the external eye alone. 

LUMBAR PUNCTURE AS AN ANAESTHETIC. 

I have seen this cocain spinal injection substitute aether 
and chloroform obtunding pain but not consciousness, both 
in this country and abroad. It is now done from the Atlantic 
to the Pacific. I saw Winslow Anderson and his able col- 
league do it in San Francisco, the patient looking on com- 
placently at her own laparotomy. 

TUFFIER'S LUMBAR PUNCTURE IN SURGICAL DIAGNOSIS 
AND PROGNOSIS. 

Tuffier's remarkable lumbar punctures have developed 
much more than therapeutic significance. Tuffier himself 
gives the operation diagnostic significance in an article in 
the Bulletin and Memoirs of the Society of Surgery last 
year (No. 27), suggesting that subarachnoid effusion of 
blood mingling with the drawn cerebro-spinal lymph meant 
internal spinal fracture. Here is a diagnostic procedure of 
importance in obscure fracture of the vertebrae, with pos- 
sible greater internal than external damage to the integrity 
of the spinal canal and the important nervous structures 
and vital centers of sensation, motion and visceral function 
which this neural bony conduit encases and protects. 

Suppose lumbar puncture had been in vogue in sur- 
gery at the time of President Garfield's fatal wounding 
and employed in that remarkable case, i. e. 9 provided that 
President Garfield had had for his medical counsel a really 
advanced expert surgeon, at the beginning of his wounding, 



409 

in full rapport with the present wonderful resources of 
neurology and surgery in diagnosis? As it was, President 
Garfield had, at the commencement of that fatal case, the 
counsel of a medical politician, more noted for his political 
pull than his surgical skill, and famed chiefly as the advo- 
cate and promoter of the now exploded Condurango cancer 
cure, that was then working marvels in the daily press, 
like the oil wells, some of the gold mines and turf ex- 
changes of the present day, and medical and other fakes 
advertised in the newspapers of our day. 

Lumbar puncture for diagnostic purposes is a procedure 
for the later stages of suspected spinal injury, either of 
the meninges, the cord proper, or the bony canal, after giv- 
ing the effused blood, which is likely to be small in quan- 
tity in the beginning, time to accumulate and stain the 
cerebro-spinal fluid. In estimating the value of this new 
lumbar puncture sign the same principles would apply to it as 
elsewhere, viz., the extent and degree of hemorrhagic dis- 
coloration. This sign might also prove useful as one ele- 
ment in the prognosis of the possible after effects to the 
cord; those sequences of concussion and molecular 
injury to the cord, which cause so much trouble to 
corporations and so much real, as well as litiga- 
tion, distress to victims of spinal injury concussion and 
cerebro- psychic shock and cause the clashing of victim and 
company, of neurologist and surgeon in the courts. 

LUMBAR PUNCTURE AND NEURO- OR CYTO-DIAGNOSIS 
GENERALLY. 
The lumbar puncture needle promises to be of as much 
service to the near and new oncoming neurology and 
surgery as the ophthalmoscope, microscope or the re- 
agents of chemistry have been and now are. Neuro- 



410 

surgical diagnosis and prognosis are even now receiving 
new impetus from them in many directions. Recently be- 
fore the Medical Society of the Paris Hospitals, many 
wonderful and valuable reports have been made of this 
method of cyto-diagnosis, beginning in October, 1900, with 
the reports of Widal and Sicard and Ravaut, his assistants, 
to whose work the Philadelphia Medical Journal refers 
editorially with well -deserved commendation. Since the 
first communication of Widal a flood of reports confirming 
the value of this method of cyto-diagnosis have appeared 
in the literature of clinical neurology and general medicine. 
Monod, as this wide-awake periodical notes, last year, in 
Paris, examined the cerebro-spinal fluid of fifty nervous 
patients, finding leucocytosis in locomotor ataxia and general 
paralysis, finding nothing significant in alcoholism, hysteria, 
hemiplegia or neuritis. Chauffard, Boinet, Rabaud, (same 
source as above, viz., Bulletins and Memoirs of the Medical 
Society of the Paris Hospitals for last year) confirmed the 
findings of Widal and his assistants in tabes and general 
paralysis. 

Many interesting showings were made by examinations 
of the fluid too lengthy for detail here, among them Nageottes' 
finding that in syphilitic meningo-myelitis mononuclear 
leucocytes predominating in the cerebro-spinal fluid, while 
in the non-specific cases the majority of the cellular ele- 
ments are polynuclear. The cerebro-spinal fluid was found 
normal in hemiplegia, brain tumor, etc. In tubercular 
meningitis, lumbar puncture showed increasing lymphocytes 
and low osmic tension, while this cerebro-spinal fluid in- 
jected into rabbits caused tuberculosis. 

Here is an important feature in which surgery may 
assure itself as to the state of the meninges after surgical 
operations and of the existence or non-existence of tuber- 



411 

culosis, perhaps of the central nervous system, when spinal 
puncture is used for anesthesia. 

The cerebro-spinal fluid after this operation should in- 
variably be saved and microcytologically examined. The 
number of leucocytes should be examined and counted. 
Laubry (same source) reported a case of supposed tu- 
bercular meningitis disproved by this form of cytodiag- 
nosis, where autopsy showed cerebellar tumor. This work 
is still going on actively in France. American surgery 
should take it up, and keep it up, until the new mine of 
diagnostic wealth shall have been worked out. In miner's 
parlance there is undoubtedly ''rich pay dirt here," for 
clinical surgery as well as for neurology. 

IDIOTROPHIC AFFINITIES AND REACTIONS OF NEURONES. 

The central neurones have their special nutritional or 
idiotrophic affinities appropriating what they need from the 
blood current for their nutrition, which means their growth, 
life and function and selecting their own peculiar manner 
of response to psychic, peripheral and toxic impression 
as we see in the phenomea of the reflexes of the brain and 
cord, the pupil reflex and the knee reflex for instance, the 
psycho- motor movements of a convulsion, the opisthotonos 
of spinal meningitis and tetanus, the tremors of sclerosis 
and paralysis agitans, the altered brain workings of convul- 
sive tic, of trigeminal neuralgia, etc. 

The physiology of the five or more senses is based on 
this peculiar reaction of central neurones to peripheral or 
central impression. They select their own special im- 
pressions of smell, taste, touch, sound, weight, etc. The 
knee kicks up, the foot jerks down, the chest expands, the 
gullet contracts downward, the bronchi and diaphragm con- 



412 

tract so as to throw air and mucus upward, as in coughing, 
when their special centers are set into reflex action by per- 
ipheral excitation, so we also have the phenomena of fecal 
and urinary expulsion, peristalsis, etc., etc. 

The irido or iris reflex is a true idio- reflex. There is 
no other like it. It contracts to light and to certain drugs 
like eserin, and expands to darkness, atropin, cocain and 
other mydriatics, ldiotrophic means, strictly speaking, from 
its derivation (when applied to a neurone or group of neu- 
rones making a nerve center), a peculiarity of nutrition or 
selection of its nutrition. But we extend its signification. 
The selective affinities of certain centers of the brain or 
cord for anesthetic, motor or sensory impression or what 
has been called the selective affinities of drugs which are 
idiotrophies of the neurones, is a subject to thoroughly 
consider, and their psychic impressibility in surgical practice. 

Barker, whose book is the bible of modern American 
neurology, as Nissl, van Gehuchten, Lenhossek, Cajal, and 
others &re abroad, and, in fact, of the mundane neurology 
of our day, for in it are the sayings of the wisest and 
best sages and apostles of our faith, concerning the doc- 
trine of the neurones, following a well- merited defense 
of Johannes Mueller, who gave to neurologic science the 
"doctrine of the specific energies of nerves," says "it has 
been left for the neurone doctrine to explain, if it can, why 
it is that on stimulation of the retina or of the optic 
nerve, for example, the response always occurs in one and 
the same manner; no matter whether the stimulation be 
by normal methods or by mechanical or electrical means, 
the sensation of light or of color alone is yielded; or how 
it happens that when a cold point on the skin is stimu- 
lated, whether it be with ice, the prick of a sharp tooth 
pick, an electric current, or a piece of hot wire (cold point 



413 

paradoxical reaction of von Frey), the sensation of cold 
always results. The constancy of the quality of the 
reaction, despite the variability in the form of the external 
stimulus, is one of the most puzzling of the phenomena 
with which the neurologist has to deal." 

To me this does not seem so puzzling in view of the idio- 
trophic properties of the neurone as I here use the term. 
Though Barker still considers the question as obscure and 
refers to well-known pathologic cases in which direct irri- 
tation of certain areas of the cortex "has called forth 
definite sense perceptions, as evidence that these sense 
perceptions speak for direct relation of these bodies to the 
specific energies of the sensory nerves." The explanation 
is in that wonderful individuality of the neurone, to which 
I have already referred as the crowning cap sheaf cytolo- 
gical discovery of the nineteenth century making the name 
of Ramon y Cajal immortal. The idiotrophic property of 
the neurone unit explains why "odors, images of colored 
objects, memories of muscular movements, and of * sounds 
have been experienced by individuals suffering from the 
pressure of cysts and other bodies upon the corresponding 
cortical sense areas," and why normal sensations reappear 
in nerve centers when limbs are removed, and why memo- 
ries of impression, psychic or physical, persist. We need 
but subject the matter to the test of reason. It appears as 
an axiomatic truth of the new cytology, that the neurone 
has this property, as the character and proof of its indi- 
viduality as distinctive and individual as the selection of 
its own reconstructive nutrition; which is as distinctive 
as its chromophile and achromatic properties. 



CHAPTER XXXVI. 

THE NUTRITION AND CONSERVATION OF THE NEURONES, OR NEU RO- 
AN D PSYCHO-NEUROTHERAPY IN SURGERY. 



The popular misconception of the surgeon is that he is 
only a cutter. This misconception extends often to the 
surgeon himself, and it is not always confined to junior 
surgeons, who might be excused for knowing no better. 
In consequence, there sometimes develops in the surgical 
mind a flippant skeptical treatment of the resources of 
medicine, especially of the wonderful modern neurotheraphy. 

The popular misconception about the neurologist is that 
he is fitted to treat only nervousness and the neuroses of 
hypochrondria, neurasthenia and the imagination, and to 
fool with a lot of chronic maladies of the cerebro-spinal axis 
and peripheral nervous system, requiring more time and 
patience than the average surgeon has to devote to them. 
But I tell you as a medical man of once extensive surgical 
practice, that neurology and neuriatry are fundamental in 
medicine and surgical practice, and they cannot be longer 
ignored in either clinical medicine nor in the most possibly 
successful clinical surgery. It is the surgeon who treats 
the whole patient, neuriatrically and psychiatrically and 
otherwise therapeutically, up to the advancing modern 
standard, who will carry the greater trophies of recovery 
in his warrior belt, as the conqueror of disease. 

[414] 



415 

There is a psychic and neural and psycho- neural anti- 
sepsis, as well as, and no less valuable, as affecting prog- 
nosis, than the antisepsis of the vascular and absorbent 
systems, which have made Lister and many of his follow- 
ers immortal and enabled modern surgery to invade and 
rescue victims of disease from the very grasp of death. 
Added to Listerism and the dauntless skill of its world ap- 
plauded votaries in your illustrious ranks, comes now mod- 
ern neuro-therapy that enables disease's prostrate and im- 
prisoned victims to hold out through judicious cytological 
reinforcement, till the new and conquering surgery accom- 
plishes its saving work and rebuilds and restores the 
assaulted central neurones. 

THE PSYCHIATRIC FACTOR IN SURGERY 

Consists in conserving the integrity of the psycho-neurones 
by withholding from the patient and avoiding both during 
and after the surgical operation, everything that may tend 
to lower mental or physical vitality. To this end blunt an- 
nouncement of an operation intended and abrupt statement 
of possible doubtful prognosis, the needless display of the sur- 
gical tray and the prelude preparations and discussion of the 
intended procedure by nurses, except under the specific, de- 
tailed directions of the surgeon, should be avoided.* 

The employment of anesthesia in our day has saved 
patients intended for the operating table much psychic 

*The little surgeon who pompously displays his tray of Instrumep's before his tremb- 
ling patient and to his woeful wondering mind decants upon the operation he is about to per- 
form, and the chances of recovery, or displays a nonchalant unfeeling mien, acts unwisely 
and does not increase his patient's chances of getting well quickly. 

And the great surgeon who takes his patient into the operating room and places him 
while conscious on the table, himself with instruments in hand, while white aproned attend- 
ants gather around the victim, approaching with sponge and bottle and Instruments and ap- 
pliances of the impending operative procedure. Is not so wise a surgeon, and does not so 
fully consider the effect of depressing psychical Influences as he who chloroforms the intend- 
ed subject of an operation in another room or in the same room without these depressingly 
suggestive influences.— Alienist and Neurologist, Oct., 1896. 



416 

shock they did not escape in the past. If to this should 
be added the anesthetizing of the patient in a cheerful 
flower decked, gratefully odored room, without any appear- 
ances of the coming bloody ordeal, and the patient wheeled 
into the operating room while anesthetically unconscious, 
psychic conditions of restive recuperative central nerve 
tone woald be enhanced. 

PSYCHICAL DEPRESSION AND THE NEUROPATHIC DIA- 
THESIS. 

As a sound neuro- surgical aphorism 1 should say, from 
the standpoint of a broad experience, avoid all sources of 
psychic depression and consider well the nervous system of 
your patient before and after every operation. There are 
some constitutions so neuropathic and psychopathically pre- 
disposed that the shock of such an announcement would 
precipitate a crisis of mental alienation and it were better 
that the proposed operation should be abandoned than in- 
sisted upon under such circumstances, or that the patient 
should be gradually approached and prepared by cautious 
speech and suitable precursory recoristructive and tranquil - 
izing neurological treatment. Many of the post* operative 
insanities and neuroses result from awakening into active 
life the psycho -neuropathic diatheses and might not result 
in neurotically well prepared or psycho- neurotically well en- 
dowed nervous organisms. 

And these, gentlemen, are the victories of modern sur- 
gery: A skilled technic never before equaled. Anesthesia, 
general, peripheral and spinal; antisepsis, cytotherapy. And 
the honors are even, for anesthesia and cytotherapy are 
ours. Antisepsis and the new operative technic are yours. 
Fortunately for mankind these advances are all in one 



417 

family and that family is one for the weal of a suffering 
world. 

POST-OPERATIVE INSANITY. 

As a suitable addendum to this chapter, let me here 
quote one of my editorial criticisms from the Alienist and 
Neurologist of October, 1901: A St. Louis surgeon having 
performed an enterorrhaphy with acute mania without 
sepsis as a sequel gives this as a rule which he declares 
has been adopted by most surgeons, viz: Under no circum- 
stances ought any insane woman to be operated upon unless 
for some distinct condition that is compromising life. 

This is not as a rule based on clinical knowledge, with 
those who have done their own surgery in a hospital for 
the insane or have advised surgical procedures on the in- 
sane. Psychiatry looks at the subject differently. A grave 
surgical disease preceding insanity or supervening a 
psychosis may be removed unless the proposal to operate 
and the preparation and operative procedure are in the line 
of and tend to aggravate the patient's delusions. Rules of 
therapeutic procedure medical, moral or surgical in psychia- 
try are out of the range of the average surgeon's clinical 
experience and he should defer to psychiatric judgment in 
the premises and not formulate rules purely from the sur- 
geon's standpoint. The practical alienist might enlighten 
surgery in some surgical quarters where surgeons walk in 
darkness and the darkness comprehendeth not. 

1 would like to ask if this is the rule adopted by most 
surgeons? If so it is not a wise one. Sources of physical 
drain and irritation should be removed, if practicable, from 
the insane and nervous as well as the sane and nervously 
well. 



L343 

H89 

| 1903 


Hughea.C.H. The 
neurological practice 
of in edi ci ne. . , 13858 


■ptn. 


ME 


DATE DUE 








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— -J